REFERRAL FORMFOR HEALTH PROFESSIONALS

PATIENT DETAILS / REFERRER DETAILS
Surname: / Referrer Name:
Forename/s: / Referrer Job Title:
Address: / Referrer Address:
Preferred Contact Numbers: / Preferred Contact Number:
Date of Birth: / Relationship to patient:
Sex: Male Female / Date of Referral: / Signature:
NHS Number: / Patient GP Name and Practice:
Name of Parent or Carer:
Does the patient need to communicate in a language other than English? Yes No
Ifyes, please specify:
Is the patient registered with a dentist? Yes / No
If yes, dentist/practice name:
When was the last time the patient had a check-up?
Less than 6 months
6 - 12 months
12 - 24 months
2 years +
Does the patient have any of the following: (please tick all that apply)
Bleeding gums / Broken teeth
Bad breath / Pain / discomfort
Dry mouth / Mouth ulcers
Loose teeth / Other: (details)
Relevant details of medical history (brief):
Reason for referral:

INFORMATION FOR GUIDANCE ONLY

The Special Care Dental Service provides dental care to certain categories of patient who are unsuitable for care within the General Dental Services (GDS) due to their special needs. The service does not see patients who could be seen by a General Dental Practitioner (GDP).

Individuals who may be referred to the Wolverhampton Special Care Dental Service:

  • Patients with severe / extreme learning disabilities
  • Patients with severe / extreme physical disability who are wheelchair bound
  • Patients who are medically compromised (American Society of Anaesthesiologists, category 3 &4)
  • Patients who have severe mental health problems
  • Children with high treatment needs who are difficult to manage
  • True dental phobic patients (by General Dental Practitioners only)
  • Very frail elderly in care homes
  • Socially excluded groups e.g. migrants and homeless people and those with substance misuse problems
  • Adults and children with severe autistic spectrum disorders
  • Children with other special needs including those with severe anxiety or other behavioural management difficulty

Patients referred by their GP or other health professional will be seen and assessed against the Service’s Acceptance Criteria (see table below) and will be accepted if they score 15 or above. If these are not met, patients will be referred on to a GDP of their choice.

CRITERION USED FOR ASSESSMENT: (DO NOT COMPLETE) / 0 / A / B / C
Ability to communicate / 0 / 2 / 4 / 8
Ability to co-operate / 0 / 3 / 6 / 12
Medical status / 0 / 2 / 6 / 12
Oral risk factors / 0 / 3 / 6 / 12
Access to oral care / 0 / 2 / 4 / 8
Legal and ethical barriers / 0 / 2 / 4 / 8

Total Score >15 is an appropriate referral score

Full details of these criteria are available at the BDA Website:

How to refer patients to the Wolverhampton Special Care Dental Service:

Please complete the referral form overleaf and send it by post, fax or email to:

Dental Management Office

Pennfields Health Centre

Upper Zoar Street

Pennfields

Wolverhampton

WV3 0JH

Tel: 01902 444186

Fax: 01902 444046

Email:

Office Administration
Date Received / Referral Accepted
Referred To / Location of Assessment
Date of Assessment / Exception report completed