clch barnet community dental referral form 1202 by dix06N


									                                       SALARIED PRIMARY CARE DENTAL SERVICE
                                                   REFERRAL FORM
                                            (Please Photocopy as Required)

Please complete all the fields on this form. Failure to do so will result in the form being returned to
the referrer. Please use BLOCK CAPITALS and write legibly.

Date of referral                        Title      Sex:   M/F

Surname/family name

Forename/first name

Date of birth                                   National Health No:

Patients Contact address
Please ensure this is correct
and up to date
                                                 Postcode :

Name of parent or carer

Contact telephone
Numbers Including Mobile Numbers
(Please ensure these are up to date)

Doctor’s (GP) Name, Address and Phone

Does the patient or parent/carer need to
communicate in a language other than
English? If yes please specify:
Referrer’s Name and Contact Details (Including Telephone Number)
Reason for referral including why the patient is unsuitable for the General Dental Service

   Which of the following criteria does the patient fulfil:

          1.       Physical difficulties resulting in mobility problems – give details

           2.       Learning disabilities – give details

           3.      Complex medical history where the medical condition or medication compromises oral health
                   or necessitates special care – give details (Including medication)

           4.      Management problems / challenging behaviour – give details of what attempts have
                   been made to provide care and what the patient cannot tolerate

          5.       Complex Social Needs – give details

          6.       Paediatric Dentistry (Children under 16) - give details

   Relevant Dental History:

I confirm that I have advised the patient that:

               The Dental Service does not offer emergency dental appointments to patients before they
                have been assessed and accepted for treatment.

Signature of Referrer: …….………………………………………

Return Address:

           Dental Office
           Vale Drive Primary Care Centre
           Vale Drive
           EN5 2ED
           HTel: 08453720327            Fax: 0208 447 3510

To top