Download Referral Form Dental Practitioner 11/16

Special Care Dental Service
Request for assessment - referral from a Dental Practitioner
NOTE: PLEASE ENSURE A CURRENT TREATMENT PLAN AND ALL RELEVANT X-RAYS ARE
ENCLOSED WITH THIS REQUEST FOR ASSESSMENT FORM.
Please ensure you complete the whole of this form, or it may be returned to the referrer for more
information.
Send completed referrals to; Exeter NHS Dental Access Centre, Royal Devon and Exeter Hospital (Heavitree),
Gladstone Road, Exeter EX1 2ED (Tel: 01392 405718) or
Barnstaple NHS Dental Access Centre, Barnstaple Health Centre, Vicarage Street, Barnstaple, EX32 7BH
(Tel: 01271 370562)
Patient’s Surname:
Forenames:
Home address:
Postcode:
Date of birth:
Contact Tel. Numbers
Gender:
Home/work:
Male
Female
Mobile:
Name of General
Medical Practitioner
Name of Referring Dentist
Name of Referring Surgery
Surgery Address
Name of GP surgery
(surgery stamp can be used)
Name of School
(if patient is a child)
First language –
Date patient last seen
if not English
Does the patient have any communication difficulties and/or need a translator?
Surgery Telephone Number
Yes
/
No
If yes, please give details:
Please tick reason for referral to Special Care Dental Service:
Learning disability
[ ]
Acquired brain injuries
[ ]
Diagnosed mental health illness
[ ]
Autistic spectrum disorders
[ ]
Current significant misuse of substances
[ ]
Child with cleft lip or palate
[ ]
Dental treatment complicated by medical condition
[ ]
Medical condition significantly affected by poor oral health
[ ]
Sensory disability making access to general dental service difficult
[ ]
Physical disability making access to general dental service difficult
[ ]
Uncooperative preschool children, or children with a phobia of dental treatment (treatment must have been
attempted in GDP prior to requesting referral)
[ ]
Please give information explaining chosen category and why patient not suitable for treatment in GDP:
Special Care Dental Service – Request for assessment – DENTIST – October 2016
When referring a child for treatment under general anaesthesia, please give justification for use of GA
(with reference to ‘Guidelines for the Management of Children Referred for Dental Extractions under
General Anaesthesia’ (APA/RCA/AAGBI/ADA/BSPD/FGDP/RCN, 2011):
Overview of patient’s medical history (please include a signed current medical history form and a
list of the patient’s current medication with the referral):
Do you have any safeguarding concerns for this patient? Yes / No
If yes, please give details: …………………………………………………………………………………………………..
Dental Treatment plan for patient (please attach Personal Dental Treatment plan form FP17DC):
Carious teeth
Do you feel the patient has capacity to consent to this treatment plan (if adult patient)? Yes / No
If no, please give details: …………………………………………………………………………………………………..
Please tick relevant box:
Is the referral request for: a single treatment
[ ]
or for ongoing care
[ ]
Outline of recent dental history / treatment attempted:
CHECKLIST Please ensure the following is enclosed:
Recent relevant X-ray(s) enclosed
[ ]
Signed medical history form enclosed
[ ]
Personal Dental Treatment plan form FP17DC enclosed
[ ]
Patient has been informed of request for assessment and the reason for referral
[ ]
Do you consider this to be an urgent referral?
Yes
[ ]
No
[ ]
If yes, please give details: …..………………………………………………………………………………………………..
Occasionally we need to amend the prescribed treatment plan as deemed necessary. If you have any particular
concerns about amending this treatment plan, please give details below:
……………………………….…………………………………………………………………………………………………..
PLEASE NOTE:
The Special Care Dental Service in Exeter does not carry out conservation of children’s teeth under GA and, in line with
the guidance from the British Society of Paediatric Dentistry, it should be explained to carers of all referred children
that undergoing a GA would usually indicate radical extractions of teeth as necessary so that further GA’s may be
prevented in the future. The Special Care Dental Service reserves the right to refer patients back to their General
Dental Practitioner if they do not fit any of the criteria the service is commissioned to provide, or if the form is not legible
or completed fully.
.
Signature of dentist:
Date of referral:
Special Care Dental Service – Request for assessment – DENTIST – October 2016