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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
