Request for Assessment - Referral from a Dental Practitioner
Special Care Dental Service
Request for assessment - referral from a Dental Practitioner
NOTE: PLEASE ENSURE A CURRENT TREATMENT PLAN AND ALL RELEVANT X-RAYS ARE ENCLOSED WITH THIS REQUEST FOR ASSESSMENT FORM.
Please ensure you complete the whole of this form,or it may be returned to the referrer for more information.
Send completed referrals to;Exeter NHS Dental Access Centre, Royal Devon and Exeter Hospital (Heavitree), Gladstone Road, Exeter EX1 2ED (Tel: 01392 405718) or
Barnstaple NHS Dental Access Centre, Barnstaple Health Centre, Vicarage Street, Barnstaple, EX32 7BH (Tel: 01271 370562)
Patient’s Surname: / Forenames:Home address:
Postcode:
Date of birth: / Gender: Male Female
Contact Tel. Numbers / Home/work: / Mobile:
Name of Referring Dentist / Name of General Medical Practitioner
Name of Referring Surgery / Name of GP surgery
Surgery Address
(surgery stamp can be used)
Surgery Telephone Number / Name of School
(if patient is a child)
Date patient last seen / First language –
if not English
Does the patient have any communication difficulties and/or need a translator? / Yes / No
If yes, please give details:
Please tick reason for referral to Special Care Dental Service:
Special Care Dental Service – Request for assessment – DENTIST – October 2016
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[ ]
Physical disability making access to general dental service difficult[ ]
Uncooperative preschool children, orchildren with a phobia of dental treatment (treatment must have been attempted in GDP prior to requesting referral) [ ]
Please give information explaining chosen category and why patient not suitable for treatment in GDP:
When referring a child for treatment under general anaesthesia, please give justification for use of GA (with reference to ‘Guidelines for the Management of Children Referred for Dental Extractions under General Anaesthesia’ (APA/RCA/AAGBI/ADA/BSPD/FGDP/RCN, 2011):
Overview of patient’smedical history (please include a signed current medical history form and a list of the patient’s current medication with the referral):
Do you have any safeguarding concerns for this patient? Yes / No
If yes, please give details: …………………………………………………………………………………………………..
Dental Treatment plan for patient(please attach Personal Dental Treatment plan formFP17DC):
Do you feel the patient has capacity to consent to this treatment plan (if adult patient)? Yes / No
If no, please give details: …………………………………………………………………………………………………..
Please tick relevant box:
Is the referral request for: a single treatment[ ] or for ongoing care[ ]
Outline of recent dental history / treatment attempted:
CHECKLISTPlease ensure the following is enclosed:
Recent relevant X-ray(s) enclosed [ ]Signed medical history form enclosed[ ]
Personal Dental Treatment plan form FP17DC enclosed[ ]
Patient has been informed of request for assessmentand the reason for referral[ ]
Do you consider this to be an urgent referral? Yes[ ]No[ ]
If yes, please give details: …..………………………………………………………………………………………………..
Occasionally we need to amend the prescribed treatment plan as deemed necessary. If you have any particular concerns about amending this treatment plan, please give details below:
……………………………….…………………………………………………………………………………………………..
PLEASE NOTE:
The Special Care Dental Service in Exeter does not carry out conservation of children’s teeth under GA and, in line with the guidance from the British Society of Paediatric Dentistry, it should be explained to carers of all referred children that undergoing a GA would usually indicate radical extractions of teeth as necessary so that further GA’s may be prevented in the future.The Special Care Dental Service reserves the right to refer patients back to their General DentalPractitioner if they do not fit any of the criteria the service is commissioned to provide, or if the form is not legible or completed fully.
Signature of dentist: / Date of referral:.
Special Care Dental Service – Request for assessment – DENTIST – October 2016