LOCALA_branded_non-GDP_referral_form_
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Locala Dental Care REFERRAL OF A PERSON TO THE COMMUNITY DENTAL SERVICE (NOT FOR DENTAL PRACTITIONERS) Patient details: Name of patient: ………………………………………………….. NHS No.………...................................... Gender …………………………………………………………….. Ethnicity ………………………………….. Address: ………………………….................................................................................................................. ................................................................................................... Postcode: .............................................. Tel: Mobile: .............................................................................. Date of Birth: ......................................... Email Address: …………………………………………………………………………………………………….. Next of kin: Name: ……….…………………………………………………................................................. Relationship: ……………………………………………………....... Tel No: ………….................................... Medical History: Medical problems: ………………………………………………………………………………………………………………………… ……………………............................………………………………………………………………………………. Medication: …………………………………………………………………..................................................... ……………………………………………………………………………………………………………………....... Allergies: ………………………………………………………………….…..................................................... Name of GMP: ……………………………………………………… Tel no: ………….................................. Address: ………………………………………………………………………................................................... GMP Email Address……………………………………………………………………………………………….. Postcode: ……………………….................................................................................................................. Mobility \ Communication: Please tick: Pain Swelling Infection Trauma Broken tooth Tooth decay Dentures Gums Other …………………………………………….................... ...........…………………………………………............ ................................................................................. ………………………………………………………….. ………………………………………………………..... Walks unaided Walks aided Wheelchair user Bedridden Domiciliary \ home visit needed Visual impairment Hearing impairment Speech impairment Special needs Communication problems Learning Disability Language ………………………………………................... Person Referring Patient: Reason for referring patient: …………………………………………………….......................................... Name of person referring patient: ………………………………………........................................................ Address of referrer: ……............................................................................................................................ .................................................................................................................................................................... Postcode: .................................................................................................................................................. Position: .………………………………………………………………….......................................................... Tel No: ….…………………………………………………................Mobile: ………………………………….. For Dental Office Use only: Date received: …...…………………………………….......... Urgent \ Routine: .....………………………….. Referral taken by: ………………………………………....... Referred to: …………………………............... Please either fax or post the form to Locala Dental Care: Patients from Dewsbury, Mirfield, Spen, Batley & Birkenshaw areas Dental Department Batley Health Centre Upper Commercial Street Batley WF17 5EP Fax Tel 01924 422944 01924 351557 Patients from all Huddersfield areas Dental Clinic Princess Royal Community Health Centre Greenhead Road Huddersfield HD1 4EW Fax Tel 01484 344241 01484 344244 Patients from all Calderdale areas Dental Clinic St John’s Health Centre Lightowler Road Halifax HX1 5NB Fax Tel 01422 330918 01422 307305 SharePoint/Dental / Referrals / Referrals into our service / Referral forms / LOCALA branded non - GDP referral form - revised Jan 2015 Review April 2015
