Download Referral Form - Sussex Community NHS Trust

Special Care Dental Service (SCDS)
Patient Referral Form – West Sussex (Please use alternative form for domiciliary referrals)
Dental Office Use Only
Date received
Clinic Allocated to
Date received
Clinician assessment of treatment need
Priority
☐ Urgent
☐ Semi-urgent
Patient to be seen by
☐ Consultant
☐ Specialist
☐ Elective
☐ Snr Dental Officer
Referrer Details
Referrer Name
☐ Dental Officer
☐ Any
Practice stamp
Practice Name
Address
Postcode
Tel No
☐ GDP
☐ GMP
☐ Health Care Professional (state title/ relationship to patient)
Patient Details
Name
☐ Male ☐ Female
Date of birth
NHS Number
Address
Postcode
Telephone No
Home -
Mobile -
Name of Parent / Guardian
Name of GP
Exempt ☐ No ☐ Yes - details
Address & Postcode of GP
Medical History – please include medication
Reason for Referral
☐ Extreme dental anxiety
☐ High caries risk (children only)
☐ Learning disability / ☐ Behavioural problems
☐ Medical problem affecting delivery of dental care
(please give details below)
Details
☐ Physical disability (please give details below)
☐ Severe mental health diagnosis (please give details below)
☐ Significant child protection or social problems
☐ Wheelchair user / ☐ Bariatric/Weight? -
☐ Referral for one course of treatment
☐ Referral for SCDS to retain (if patient meets criteria)
SCDS do not provide intravenous sedation for phobic adults & children. We do provide inhalational sedation.
Does the patient require an interpreter?
Does the patient have capacity to consent if an adult?
☐ No ☐ Yes what language?
☐ No ☐ Yes
Clinical Information – Please complete in full
Proposed treatment plan
What attempts have been made to provide care, including details of any urgent treatment provided and what
has the patient been unable to tolerate?
Why is the patient not suitable for care in a General Dental Surgery? Please explain in detail why you are
referring this patient and details of patient’s ability to cope with dental treatment tried.
Have radiographs been taken? If not, why? Please include copies of relevant radiographs.
For paediatric patients, if permanent teeth are to be extracted, or have large cavities they may benefit from the
following prior to our appointment:
 An orthodontic second opinion regarding the poor prognosis of some of the permanent teeth.
 A DPT/OPG – the orthodontist may have taken this during their assessment of the patient and may be able to
provide a copy.
We would be grateful if you could refer the patient for an orthodontic second opinion. If this is the case, please send
their second opinion (including a copy of the OPG if they had on taken) with this referral to speed up the patients
dental treatment. Please note we do not provide orthodontic extractions
Please continue to see your patient particularly for emergency care.
I confirm that I have advised the patient that:
 SCDS only provide care to certain categories of patient and they will be assessed against the services acceptance
criteria. If these are not fulfilled the patient will not be accepted for care.
 SCDS do not offer emergency dental appointments to patients that are not retained under the services retention
criteria. Emergency care provision is the responsibility of the referring dentist.
Signed (Referrer)
Date
Patient / Parent / Carer Signature
Date
Printed Name / Relation to patient
Failure to complete this form in full will cause delay and will be returned to you.
Please return completed form to: Dental Referrals, Special Care Dental Service,
Haywards Heath Health Centre, Heath Road, Haywards Heath, West Sussex, RH16 3BB
Patient Referral form/February 2017 – V1.0