Special Care Dentistry
PATIENT REFERRAL
(Please use alternative form for Domiciliary or GA referrals)
DENTAL OFFICE USE ONLY:
Date Received..........................
DENTAL CLINIC USE ONLY:
Date received...........................
Allocated to ..............................Clinic
DENTAL CLINIC USE ONLY:
Priority: Urgent
SDO/LEAD CLINICIAN ASSESSMENT
OF TX NEED:
Semi-Urgent
Elective
Book with: Consultant /Specialist /SDO /DO /Any
REFERRER DETAILS:
Practice Stamp
Name......................................................................
Address...................................................................
………….….............................................................
Postcode............................................................. Tel No................................................................
GDP
GMP
Health Care Professional – Title
Other -
PATIENT DETAILS
Forename...............................................................
Surname........................................................................
Date of Birth............................................................................
Male
Female
Address
...........................................................................................................................................................................
.................................................................................................Postcode ......................................................
Tel No....................................................................
Name of Parent/ Guardian/ Carer ....................................... Tel No ..............................................
NHS Number .................................................... Exempt Y/ N ? (Details)..........................................................
Name/Address of GP…………………………………………………………………….…………………………..
MEDICAL HISTORY: Please include medication
REASON FOR REFERRAL: Please give full details below
Learning disability
Physical disability
Mental health diagnosis
Medical problem affecting delivery of dental care
Looked after children/on Child
Protection Register
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High Disease Level (children only)
(High disease defined as at least 3 carious teeth in an under 10 year old patient)
Dental phobia/Challenging behaviour/Severe management difficulties
Referral for one COT
Referral for SCD to retain (only if patient meets the retention criteria)
Details:
Please note: Special Care Dentistry does not provide intravenous sedation.
We can provide inhalational sedation.
Dentists referring patients for GA must use the Dental Service GA referral form.
CLINICAL INFORMATION: (please complete in full)
Proposed treatment plan:
What attempts have been made to provide care, including details of any urgent treatment provided
and what has the patient been unable to tolerate?
Why is the patient not suitable for care in a General Dental Surgery?
For paediatric patients, if permanent teeth are to be extracted, or have large cavities they may benefit from
the following prior to our appointment:
 An orthodontic second opinion regarding the poor prognosis of some of the permanent teeth.
 A DPT/OPG- the orthodontist may have taken this during their assessment of the patient and may
be able to provide a copy.
We would be grateful if you could refer the patient for an orthodontic second opinion, if this is the case and
send their 2nd opinion (including a copy of the OPG if they had one taken) with this referral to speed up the
patient’s dental treatment.
I confirm that I have advised the patient that:
 Special Care Dentistry only provides care to certain categories of patient and they will be assessed
against the service’s acceptance criteria. If these are not fulfilled the patient will not be accepted for
care.
 Special Care Dentistry does not offer emergency dental appointments to patients not retained under
the service’s retention criteria. Emergency care provision is the responsibility of the referring dentist.
Signed....................................................................................................
Date......................................
Patient/Parent/Carer Signature..............................................................
Date......................................
Failure to complete this form will cause delay and the form will be returned to you to be
completed fully.
Please return completed form to: Dental Referrals, Special Care Dentistry, Haywards Heath Health Centre,
Heath Road, Haywards Heath, West Sussex, RH16 3BB
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