Online referral formReferral FormStep 1 of 520%SECTION 1 REFERRAL INFORMATIONDo you consider this to be an urgent referral?* Yes NoPlease state whyType of referral Specialist Opinion only Specialist Opinion and TreatmentSECTION 2 PATIENT DETAILFirst nameSurnameAddress Street Address Address Line 2 Town/City County Post code Home tel. no.Mobile numberEmail Enter Email Confirm Email Date of birth DD slash MM slash YYYY Name of School/Nursery (if patient under 16)Gender Male Female OtherNHS NumberSECTION 3 PARENT/CARER/GUARDIAN INFORMATIONFirst nameSurnameAddress Street Address Address Line 2 Town/City County Post code Home tel. no.Mobile numberEmail Enter Email Confirm Email Relationship to patientIs there a social worker or learning disability team involved? YesPlease give detailsSECTION 4 REFERRER DETAILSFirst nameSurnameRegistration number GDC/GMCAddress Street Address Address Line 2 Town/City County Post code Tel. no.Referrer email* Enter Email Confirm Email SECTION 5 PATIENT GP DETAILS (if not the referrer)First nameSurnamePractice Address*Please make sure every box is completed Street Address Address Line 2 Town/City County Post code Practice Tel. No.*Email Enter Email Confirm Email SECTION 6 COMMUNICATION AND SPECIAL REQUIREMENTSFirst language if not EnglishInterpreter required YesSensory impairment Hearing Vision CommunicationMobility Can manage stairs Can walk with frame Can weight bear Wheelchair user Can transfer by self Wheelchair tipper required Hoisting requiredDoes the patient have any additional needs?please tick all that apply Learning disability Acquired brain injuries Diagnosed mental health illness Autistic spectrum disorders Current significant misuse of substances Child with cleft lip or palate Dental treatment complicated by medical condition Medical condition significantly affected by poor oral health Sensory disability making access to general dental service difficult Children with a high level of anxiety or children with a phobia of dental treatment and/or children with behavioural difficulties (treatment must have been attempted in GDP first) Physical disability making access to general dental service difficult Access to bariatric chair needed (patient is over 21 stone / 133 kg)please specify the weight of the patientSECTION 7 REASON FOR REFERRAL AND TREATMENT REQUESTEDPlease explain why you are referring the patient and what treatment is requiredExtractionsRight (upper) Right (upper) 8 Extraction Right (upper) 7 Extraction Right (upper) 6 Extraction Right (upper) 5 Extraction Right (upper) 4 Extraction Right (upper) 3 Extraction Right (upper) 2 Extraction Right (upper) 1 ExtractionRight (lower) Right (lower) 8 Extraction Right (lower) 7 Extraction Right (lower) 6 Extraction Right (lower) 5 Extraction Right (lower) 4 Extraction Right (lower) 3 Extraction Right (lower) 2 Extraction Right (lower) 1 ExtractionLeft (upper) Left (upper) 8 Extraction Left (upper) 7 Extraction Left (upper) 6 Extraction Left (upper) 5 Extraction Left (upper) 4 Extraction Left (upper) 3 Extraction Left (upper) 2 Extraction Left (upper) 1 ExtractionLeft (lower) Left (lower) 8 Extraction Left (lower) 7 Extraction Left (lower) 6 Extraction Left (lower) 5 Extraction Left (lower) 4 Extraction Left (lower) 3 Extraction Left (lower) 2 Extraction Left (lower) 1 ExtractionRight (upper) Right (upper) E Extraction Right (upper) D Extraction Right (upper) C Extraction Right (upper) B Extraction Right (upper) A ExtractionRight (lower) Right (lower) E Extraction Right (lower) D Extraction Right (lower) C Extraction Right (lower) B Extraction Right (lower) A ExtractionLeft (upper) Left (upper) E Extraction Left (upper) D Extraction Left (upper) C Extraction Left (upper) B Extraction Left (upper) A ExtractionLeft (lower) Left (lower) E Extraction Left (lower) D Extraction Left (lower) C Extraction Left (lower) B Extraction Left (lower) A ExtractionRestorationsRight (upper) Right (upper) 8 Restoration Right (upper) 7 Restoration Right (upper) 6 Restoration Right (upper) 5 Restoration Right (upper) 4 Restoration Right (upper) 3 Restoration Right (upper) 2 Restoration Right (upper) 1 RestorationRight (lower) Right (lower) 8 Restoration Right (lower) 7 Restoration Right (lower) 6 Restoration Right (lower) 5 Restoration Right (lower) 4 Restoration Right (lower) 3 Restoration Right (lower) 2 Restoration Right (lower) 1 RestorationLeft (upper) Left (upper) 8 Restoration Left (upper) 7 Restoration Left (upper) 6 Restoration Left (upper) 5 Restoration Left (upper) 4 Restoration Left (upper) 3 Restoration Left (upper) 2 Restoration Left (upper) 1 RestorationLeft (lower) Left (lower) 8 Restoration Left (lower) 7 Restoration Left (lower) 6 Restoration Left (lower) 5 Restoration Left (lower) 4 Restoration Left (lower) 3 Restoration Left (lower) 2 Restoration Left (lower) 1 RestorationRight (upper) Right (upper) E Restoration Right (upper) D Restoration Right (upper) C Restoration Right (upper) B Restoration Right (upper) A RestorationRight (lower) Right (lower) E Restoration Right (lower) D Restoration Right (lower) C Restoration Right (lower) B Restoration Right (lower) A RestorationLeft (upper) Left (upper) E Restoration Left (upper) D Restoration Left (upper) C Restoration Left (upper) B Restoration Left (upper) A RestorationLeft (lower) Left (lower) E Restoration Left (lower) D Restoration Left (lower) C Restoration Left (lower) B Restoration Left (lower) A RestorationOtherSECTION 8 DESCRIBE PREVIOUS ATTEMPTS AT TREATMENTPlease explain what treatment attempted and why the patient cannot be treated within General Dental PracticeSECTION 9 RADIOGRAPHSRadiographs attached DPT Intra Orals NoneGive reasonFile Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. SECTION 10 CHECKLISTThe above referral has been discussed and agreed with the patient and/or Parent/Guardian* YesHas an orthodontic opinion been sought? Yes NoPlease attach orthodontic opinion above in Section 9 or write details belowI understand that the final decision for treatment offered rests with the PCDS Dental Officer following discussions with the patient/parent/carer. When appropriate, consultation with the General Dental Practitioner will be undertaken* YesI understand that NHS charges are payable to PCDS unless the patient is exempt and that NHS charges have only been raised for treatment already carried out.* YesI have enclosed a Personal Treatment Plan form FP17RN. Charges will be payable for work carried out by PCDS.* Yes NoFile Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. if no why not?Recent relevant X-ray enclosed* Yes NoIf no why not?I confirm that this patient referral meets the current referral guidelines. I understand that incomplete and/or inappropriate referrals will be returned for revision and may delay patient treatment.* YesSECTION 13 PATIENT'S DETAILSPatient's name*Date of birth* MM slash DD slash YYYY Copy of dental practice medical history form Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Signed Primary Care Dental Service medical history form/appropriate practice medical history form attached* YesSECTION 14 PATIENT MEDICATIONSPlease list all current medicationsSECTION 15 CONFIDENTIAL MEDICAL HISTORY FORMPlease complete this section if you didn’t upload a copy of dental practice medical history.Has the patient ever been admitted to hospital? Yes NoDetails - please stateHas the patient had any operations? Yes NoDetails - please stateIs this patient attending or receiving treatment from a doctor, hospital, clinic or specialist? Yes NoDetails - please stateHas the patient ever had a general anaesthetic? Yes NoDetails - where, when and what for?Has the patient had a bad reaction to a general or local anaesthetic? Yes NoDetails - please stateIs the patient taking any medicines (tablets, creams, ointments, injections, other – including Warfarin, aspirin, contraceptives and HRT) or alternative remedies? Please specify Please bring repeat prescription/MARS sheet (if applicable) Yes NoDetails - please stateIs the patient taking or has taken steroids in the last two years? Yes NoDetails - please stateIs the patient using or has ever used recreational drugs? Yes NoDetails - please stateIs patient allergic to any medicines or food substances? Yes NoDetails - please stateDoes the patient suffer from Parkinson’s disease, motor neurone disease, or other neurological condition? Yes NoDetails - please stateHas the patient ever been told they have a heart murmur, heart disease, high blood pressure, angina, heart attack, stroke or heart surgery? Yes NoDetails - please stateDoes the patient have a pacemaker, VNS implant, stent, artificial valve, shunt, or other form of implant? Yes NoDetails - please stateHas the patient ever had jaundice, liver, kidney disease or hepatitis? Yes NoDetails - please stateDoes the patient suffer from allergies e.g hay fever or eczema? Yes NoDetails - please stateDoes the patient suffer from bronchitis, asthma or other chest conditions/snoring/sleep apnoea? Yes NoDetails - please stateDoes the patient have fainting attacks, giddiness, blackouts or epilepsy? Yes NoDetails - please stateDoes the patient have diabetes? Yes NoDetails - please stateDoes the patient have anaemia? Yes NoDetails - please stateHas the patient ever bled excessively? Yes NoDetails - please stateDoes the patient suffer from any infectious diseases (including HIV, Hepatitis B or C)? Yes NoDetails - please stateHas the patient ever been notified for public health purposes that they are at risk of CJD or vCJD? Yes NoDetails - please stateDoes the patient carry a warning card or a medi alert? Yes NoDetails - please stateDoes the patient have a TEP (Treatment Escalation Plan) – sometimes known as DNAR (Do Not Attempt Resuscitation)? Yes NoDetails - please stateDoes the patient drink alcohol? Yes NoDetails - how many units per weekDoes the patient smoke or chew tobacco products – if so, how many per week? Yes NoDetails - please stateDoes the patient wish to receive advice about stopping smoking? Yes NoDetails - please stateDoes the patient have any physical, visual or hearing problems? Yes NoDetails - please stateDoes the patient have any behavioural or learning disabilities? Yes NoDetails - please stateDoes the patient have an Autism Spectrum Condition, or ADHD? Yes NoDetails - please stateHas the patient ever had any mental health problems, including anxiety and panic attacks? Yes NoDetails - please stateIs the patient pregnant or breastfeeding? Yes NoDetails - please stateIs there anything else the dentist should know? Yes NoDetails - please stateConsent to send on behalf of the patient* Yes NoIf no why not? Last updated: October 7, 2020
