Health, Education or Social Care Professional

Name *

Job role *

Address *

Postcode *

Email Address *

Telephone Number *

Fax Number

Date of Completion *

Patient Details

Name *

Date of Birth *

Address *

Postcode *

Telephone Number *

Mobile Number

Email Address *

NHS Number

Ethnicity

Parent/Guardian/Carer Name *

Relationship to patient

Patient has consented to information sharing? *

Yes

Medical History

Medical history *

Allergies

General Medical Practitioner (Doctor's) Name *

Address

Telephone Number

Specialist name and title

Hospital

Medication *

Mobility and Communication

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this patient or their parent/carer? *

Tick the relevant boxes

Hoist required Domiciliary/home visit required

Wheelchair user

Special needs or other

Please note we have a strict triage in place for requests for home visits. We are limited to what treatment can be provided. If the patient is able to leave their home it is safer to receive their treatment in the dental surgery.

Reason for referring patient

History of present complaint *

Reason for referral *

Bariatric Medical Conditions Behavioural Management Looked after Child

Special Needs Learning Difficulties Mental Health Conditions

Dental Referral Form