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Emergency

Referral

Welcome to our online Referral submission.

Please fill out the ‘Referral Form’ information, upload any files and click the ‘submit’ button.

Alternatively, you can download and save a copy of the Referral Form here and fax or post it to us.

Please fax the form to: (028 90) 681110

by post…

Curran Oral Surgery Clinic
434 Lisburn Road
Belfast
BT9 6GR

If you require any further information you can call us on:
028 90 667 979 or email us: info@currandental.co.uk

*Please check your spam folder for form receipt after submission.

Please fill out all details and hit the ‘submit’ button to send referral:

Curran Surgery Web Referral Service

Patient Name*

First

Last

Patient Date of Birth*

day

/

month

/

year

Patients address & postcode:
Street Address*

City Post Code Country

Mobile Number:

Telephone Number:*

Payment source *

NHS

Private

If NHS is patient exempt:

YES

NO

Health and care number (Essential for NHS Referrals)*

Interpreter required: *

YES

NO

If YES specify language:

Medicial History – Include a list of patients medical conditions:

Medications – List of current medications:

Allergies:

Smoking:

Alcohol:

Mobility issues – Wheelchair user or requires downstairs surgery*

YES

NO

Patients GP Name, practice address & Postcode:

Patients GP Telephone Number:

Reason for referral:*

OPT

Assessment

Dental Extraction(s)

Orthodontic Pilot

Biopsy

History – Please include a summary of symptoms, diagnosis, treatment completed to date & treatment required:

Extractions required: (Please see diagram for reference)

Extractions required: For extractions please list the teeth/roots to be removed below:

Treatment Modality: *Please complete a seperate pre-sedation assessment form and send with referral. Patients must be provided with pre-sedation instructions available on this website under ‘Patient Information’ prior to attending their appointment*

Patients having I.V. sedation should fast for 2 hours prior to appointment and be accompanied by a responsible adult, who can take them home and look after them for approx. 24 hours following treatment*.
*

Local Anaesthetic

IV Sedation

RA Sedation

Radiograph(s) included – Radiographs must be included, please supply IOPA of third molars if cannot access OPT*

YES

NO

Date radiograph(s) taken:

Reason radiograph(s) not included:

Would you prefer this patient to be seen by a particular clinician? *

YES

NO

If yes, which clinician?

Referring Dentist Name*

First

Last

Referring Practice email
(Please remember to use your official practice email address here)*

Upload a file (Allowed formats: jpg, jpeg, png, gif, bmp, tif, tiff, pdf)

Verify*

Business Address

Curran Oral Surgery Clinic
434 Lisburn Road
Belfast
BT9 6GR

t: 028 90 667979
e: info@currandental.co.uk

About us

The Curran Surgery is a referral only practice carrying out NHS and private oral surgery treatments.

For Dentists wanting to make a Referral please use the following links

ONLINE 'REFERRAL FORM' SUBMISSION

ONLINE 'REFERRAL OF OPG' SUBMISSION

Opening Hours

Monday to Friday 9am - 5pm

Patient Info
Referral
Referral of OPG
Team
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