Download Locala Dental Care REFERRAL FORM FOR DENTAL

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Locala Dental Care
REFERRAL FORM FOR DENTAL PRACTITIONERS
(NOT FOR GA EXODONTIA)
If referring for GA exodontia please use DenGA1-99, DenGA2-99 and DenGA3-99
(ordered via dental stationery request form from Broad Lea House, Bradley Business Park, Dyson
Wood Lane, Bradley, Huddersfield, HD2 1GZ)
Please complete both sides and every section of this form and retain a copy for your records.
Incomplete referrals will be returned.
PLEASE COMPLETE FORM IN BLOCK LETTERS
Referring Dental Practitioner
Name …………………………………………………………….......
Title ………………………………………………………………......
Address ……………………………………………………………...
…………………………………………………………………….......
…………………………………………………………………….......
…………………………………………………………………….......
Tel. No. …………………………………………………………......
Fax No.…………………………………………………………........
Practice Stamp
Patient details
Name ……………………………………………………………………………………………………………...........
Date of Birth ……………………………………………………………………………………………………............
Address …………………………………………………………………………………………………………...........
……………………………………………………………………………………………………………………...........
……………………………………………………………………………………………………………………...........
Postcode ………………………………………………………………………………………………………….........
Tel. No………………………………………………………..Mobile No. ……………………………………............
NHS No. (If known) …………………………………………………………………………………..………............
Parent/guardian Name ………………………………….. Relationship to patient…………………….…...........
Medical History
Relevant medical details
Medication
………………………………………………………………………………………………….....
……….....................................................................................................................................................
………………………………………………………………………………………………………………….…
…………………………………………………………………………………………………………………....
………………………………………………………………………………………………………………….…
……………………………………………………………………………………………………………………
Allergies ………………………………………………………………………………………………………….
GMP Name ………………………………………………………………………………………………….….
Address ……………………………………………….………….......
Tel. No. ………………………………………………………………
Specialist name and title..........................................................
Hospital …………………………………………………………........
Mobility and Communication
 Hoist required
 Wheelchair user
 Domiciliary/home visit required (reason) ………………………………………………………………..........
 Interpreter required (only available via phone line) ………………………………………………….............
 Other (please specify) ……………………………………………………………………………………..........
Reason for referring patient (please refer to our Acceptance & Discharge Policy criteria)
History of present complaint …………………………………………………………………………………….........
………………………………………………………………………………………………………………….…...........
……………………………………………………………………………………………………………………............
Past dental history …………………………………………………………………………………………….….........
……………………………………………………………………………………………………………………............
……………………………………………………………………………………………………………………............
Dental treatment attempted for current condition (please state)………………………………………….…........
……………………………………………………………………………………………………………………............
Reason for referral
 Request for opinion only
 Request to investigate and treat
RADIOGRAPHS
RELEVANT RADIOGRAPHS SHOULD BE SENT. PLEASE NOTE IF THESE ARE NOT INCLUDED THIS
WILL LEAD TO A DELAY IN THE PATIENTS TREATMENT
Name of Dental Practitioner ………………………………………………………………………………….….........
Signed …………………………………………………………………………………………………………..............
Date ………………………………………………………………………………………………………………..........
Please either fax or post to Locala Dental Care
Patients from Dewsbury, Mirfield, Spen, Batley & Birkenshaw areas
Dental Department , Batley Health Centre, Upper Commercial Street, Batley, WF17 5ED
Fax
01924 422944
Tel
01924 351557
Patients from all Huddersfield areas
Dental Clinic , Princess Royal Community Health Centre, Greenhead Road, Huddersfield, HD1 4EW
Fax
01484 344241
Tel
01484 344244
Patients from all Calderdale areas
Dental Clinic, St John’s Health Centre, Lightowler Road, Halifax, HX1 5NB
Fax
01422 330918
Tel
01422 307305
For Admin. Use only Date referral received …………….Clinician……………………………………..........
 Referral incomplete – returned
 Referral does not meet acceptance and discharge protocol – returned
 Referral meets criteria – appointment ……………………………………………………………………......
-with ……………………………………………………………………………….....
 urgent
 routine
SharePoint/Dental / Referrals / Referrals into our service / Referral forms / LOCALA branded GDP referral form - revised sept 2013
Review April 2014