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Referral Form B - Children
Dorset Paediatric Dental Service
Referral for Dental Care for Children with Additional Needs
See www.sompar.nhs.uk/dental/referrals-dorset or telephone 01202 691520 ext 25 for more information
Please return to:
To be completed by the referring Dentist:
Canford Heath Clinic
Culliford Crescent
Poole
Dorset
BH17 9DW
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 Canford Heath Clinic, Culliford Crescent, Poole, Dorset, BH17 9DW
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
Please enclose a Personal Treatment Plan form FP17RN (if applicable).
If your referral does not meet the Paediatric 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
Admin only:
Referral form reviewed
by:
Priority (1,2,or3)
Date:
Comments
Please return to Canford Heath Clinic, Culliford Crescent, Poole, Dorset,
BH17 9DW