Download Taunton Dental Access Centre

Somerset Primary Care Dental Service
Referral for Dental Care for Patients with Additional Needs
Referral Form B
NB Please use Form A to refer for surgical procedures
See www.sompar.nhs.uk/dental/referrals-somerset or telephone 01278 411630 for more information
TAUNTON
YEOVIL
To be completed by the referring Dentist:
Please circle below the most convenient location for the
patient to attend and return to the Referral Management
Centre, Ground Floor, Mallard Court, Express Park,
Bridgwater TA6 4RN, in the envelope supplied.
MINEHEAD
CHARD
WELLINGTON
GLASTONBURY
BRIDGWATER
WELLS
BURNHAM-ON-SEA
FROME
PATIENT DETAILS Mr/Miss/Mrs/Ms
Name and Address of Referring Dentist
First Name
Surname
Address
Telephone
Postcode
Name and Address of Doctor
Date of Birth
Male/Female
Home Tel No
First Language if
not English
Work/Mobile Tel No.
Telephone
Reasons for referral
Treatment requested
Describe previous attempts at treatment
Radiographs are required for patient assessment. Please ensure all relevant and other recent
radiographs are enclosed
Xrays enclosed
DPT
Intra
Orals
None
(reason)
For more information on our referral acceptance criteria please visit
www.sompar.nhs.uk/dental
Please return to the Referral Management Centre
CONFIDENTIAL MEDICAL HISTORY FORM
Please tick Yes/No giving any relevant details
No Yes
If ‘Yes’ please give
details:
Has the patient ever had a general anaesthetic?
If YES, where, when and what for?
Has the patient suffered from any of the following?: If YES, please give details
Heart conditions
Diabetes
Allergies, e.g. hayfever
Fits or convulsions
Fainting or blackouts
Bleeding problems
Jaundice
Asthma, bronchitis or any other chest complaint
Any other serious illness
If YES please specify
Does the patient smoke?
Is the patient pregnant?
Is the patient allergic to penicillin or any other drugs or medicine?
If YES, please give drug name
Please list in this box any medications the patient is taking and what illnesses they are for.
Please ensure the checklist below is complete:
Please Tick 
The above referral has been discussed and agreed with the patient and/or Parent/Guardian
I understand that the final decision for treatment offered rests with the PCDS Dental Officer
following discussions with the patient/parent. When appropriate, consultation with the
General Dental Practitioner will be undertaken
I understand that NHS charges are payable to PCDS unless the patient is exempt and that
NHS charges have only been raised for treatment already carried out.
Please enclose a Personal Treatment Plan form FP17RN. Charges will be payable for work
carried out by PCDS.
If your referral does not meet the Primary Care Dental Service criteria or if this form is not legible or
completed fully, we reserve the right to return it to you.
GDC
Dentist’s Signature
Print Name
Date
Number
PCDS Admin only:
Triage1:
DAC:
Priority (1,2,or3)
Referral form reviewed
by:
Accepted/Rejected, reason if rejected
Date:
Comments
PCDS Admin only:
Triage 2:
DAC:
Priority (1,2,or3)
Referral form reviewed
by:
Accepted/Rejected, reason if rejected
Date:
Comments
Please return to the Referral Management Centre, Ground Floor, Mallard
Court, Express Park, Bridgwater TA6 4RN, in the envelope supplied.