Download Special Care Dental Service Referral Form

PLEASE RETURN THIS FORM TO:
Warwickshire Special Care Dental Service,
Whitnash Lodge – Booking & Access Team
Leamington Hospital
Heathcote Lane,
Heathcote,
Warwick, CV34 6SR,
or Fax: 01926 339230
WARWICKSHIRE SPECIAL CARE DENTAL SERVICE
REFERRAL FORM
Patients with disabilities, medical conditions or phobia/tolerance problems at
severe end of the spectrum only
Patient’s Details: (Mr/Mast/Mrs/Miss/Ms)
Dentist Details:
Surname:
Referring Dentist:
Forename:
Dental Practice Address:
Address:
Postcode:
Phone No:
Date of Birth:
NHS No:
General Practitioner:
Postcode:
Phone No:
Date of Referral:
Please tick:
Urgent

Routine

(Referral will be returned if not provided)
Name:
GP Address:
Postcode:
Phone No:
Is the patient in pain?
No

Yes - Mild /Intermittent

Yes – Severe/Continuous

Has the patient had an Orthodontic
opinion?
Yes

(Please attach a copy)
No

(Please refer to our Special Care Referring guidelines on how
to proceed)
Relevant Medical History & Medication:
REASON FOR REFERRAL: (Radiographs are required for extractions of adult teeth – please ensure they are
available with this referral)
Physical Access: Unable to access surgery/transfer to dental chair?
Phobia/Tolerance Problems:
Yes 
No 
(Only accepted with evidence of reasonable attempts having been made to provide treatment for those who can tolerate
examination. Patients who demonstrate an ability to tolerate the aspects below on assessment will not be accepted.)
Has a dental examination been possible with the patient lying supine?
If yes, what attempts have been made to provide dental treatment?
Which aspects is the patient unable to tolerate?
Instrumentation 
Air 
Water 
Other

- Please detail:
Suction

Yes 
No 
Local Anaesthetic
Please ensure you have completed and attached all essential relevant information.
Failure to do so may result in the referral being declined.
