REFERRAL TO THE HULL AND EAST RIDING COMMUNITY DENTAL SERVICE

CHILD 0-16 YEARS

* Mandatory Fields

PATIENT DETAILS
Title / Referral Date *
Forenames* / Surname*
Gender (P) / M / F / NHS Number
Telephone Number* / DOB*
Address*
Postcode* / Ethnicity
Address of School/Nursery
MAIN CARER DETAILS
Full Name
Address
Telephone Number:
Email Address
Is an interpreter required?* (P) / Yes / No / If yes, please indicate preferred language or requirements
Please confirm if Interpreter was present on completion of this form (P) / Yes / No
REFERRER DETAILS
Patient does not have a dentist* (P) / I am the referring dentist* (P)
Name*
Job Title*
Practice Address*
Postcode*
Telephone number*
Email Address* (nhs.net if available)
PATIENT GENERAL MEDICAL PRACTITIONER (GMP) DETAILS
Name
Practice Address*
Postcode*
Telephone number*
REASON FOR REFERRAL* (please see referral criteria) (P)
comments
Complex Physical disability
Complex Medical conditions
Severe Pain and Anxiety Management
Learning disability / Autism / ADHD
Looked after Children / Safeguarding concerns
Children with poor co-operation / anxiety
Dental development conditions
(including hypodontia, Amelogenesis and Dentinogenesis Imperfecta, Molar Incisal Hypomineralisation)
Trauma
Erosion (severe)
Other (please specify):
If patient has multiple carious primary teeth, or abscesses then a referral to the GA Assessment Service should be made NOT a referral on this form
DENTAL TREATMENT
What dental treatment does the patient need?* (please state)
ABILITY TO CO-OPERATE
What treatment have you attempted to provide?* (please state)
What difficulties were encountered?* (please state)
Radiographs Taken: o Bite wings o Pan Oral o Periapical o Other
If no please give reason why not
MEDICAL HISTORY* (P)
  • History of Heart Disease
  • Diabetes
  • Asthma / Respiratory Disease
  • Learning disability (elaborate below)
  • Developmental delay (elaborate below)
  • Physical disability (elaborate below)
  • Fits, convulsions, blackouts, epilepsy
  • Bleeding
  • Other, please state
/
  • Liver or Kidney Disease
  • Anaemia
  • Hepatitis or Jaundice
  • Allergies (esp. to any medication or latex)
  • Taking oral anticoagulants / bisphosphonates
  • Had any operations under general anaesthesia
  • Waiting for a hospital appointment or operation
  • Sickle cell or Thalassaemia disease or trait

List of Medications being taken
Is there anything else about the patient’s health that we need to know about?
REFERRER DECLARATION * (P)
0 I have explained to the patient and/or parent / carer that I am referring them to Hull and East Riding Community Dental Service for the reason / treatment detailed above.
0 The patient and/or parent / legal guardian has agreed to this referral.
REFERRER SIGNATURE* / DATE*
Please send the completed referral form and relevant radiographic images to:
Community Dental Service, The Orchard Centre, 210 Orchard Park Road, Hull, HU6 9BX