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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
