Please return to The Browning Centre, 7 Shelley Road, Bournemouth, Dorset, BH1 4JQ

Dorset Adult Special Care Dental Service

Referral for Dental Care for Adult Patients with Additional Needs

See telephone 01278 411630for more information

To be completed by the referring Dentist: / Please return to The Browning Centre, 7 Shelley Road, Bournemouth, Dorset, BH1 4JQ
Name and Address of Referring Dentist / PATIENT DETAILS Mr/Miss/Mrs/Ms
Telephone / First Name
Surname
Address
Postcode
Name and Address of Doctor / Date of Birth / Male/Female / First Language if not English
Telephone
Home Tel No / Work/Mobile Tel No.
Reasons for referral
Treatment requested
Describe previous attempts at treatment
Type of service likely required / IV sedation / General Anaesthetic / Don’t know (reason)
Is transport required? / Yes / No / Don’t Know
Radiographs are required for patient assessment. Please ensure all relevant and other recent radiographs are enclosed
Xrays enclosed / DPT / Intra Orals / None (reason)

CONFIDENTIAL MEDICAL HISTORY FORM

Please tick Yes/No giving any relevant details / No / Yes / If ‘Yes’ please give details:
Has the patient ever had a general anaesthetic?
If YES, where, when and what for?
Has the patient suffered from any of the following?: If YES, please give details
Heart conditions
Diabetes
Allergies, e.g. hayfever
Fits or convulsions
Fainting or blackouts
Bleeding problems
Jaundice
Asthma, bronchitis or any other chest complaint
Any other serious illness
If YES please specify
Does the patient smoke?
Is the patient pregnant?
Is the patient allergic to penicillin or any other drugs or medicine?
If YES, please give drug name
Does the patient have any disabilities?
If YES, please state
Please list in this box any medications the patient is taking and what illnesses they are for.
Please ensure the checklist below is complete: Please Tick 
The above referral has been discussed and agreed with the patient and/or Parent/Guardian
I understand that the final decision for treatment offered rests with the PCDS Dental Officer following discussions with the patient/parent. When appropriate, consultation with the General Dental Practitioner will be undertaken
I understand that NHS charges are payable unless the patient is exempt and that NHS charges have only been raised for treatment already carried out.
Please enclose a Personal Treatment Plan form FP17RN. Charges will be payable for work carried out by Dorset Adult Special Care Dental Service.
If your referral does not meet the Service criteria or if this form is not legible or completed fully, we reserve the right to return it to you.
Dentist’s Signature / Print Name / GDC Number / Date
Admin only: / Referral form reviewed by: / Comments
Priority (1,2,or3) / Date:

The Browning Centre, 7 Shelley Road, Bournemouth, Dorset, BH1 4JQ