Northumbria Community Dental Services Referral

Section 1: Patient details

1: Patient title

2: Patient forname

3: Patient surname

4: Patient gender

5: Patient NHS number

6: Patient date of birth

Section 2: Patient contact details

8: Patient contact number _{Alternative contact number}

9: Patient address

10: Patient postcode

11: Patient email address

Section 3: Parent/carer/guardian contact details

12: Parent/carer/guardian full name

13: Parent/carer/guardian address

14: Parent/carer/guardian postcode

15: Parent/carer/guardian contact number _{Alternative contact number}

Section 4: Communication and additional support

16: Does the patient require an interpreter?

Yes

18: Does the patient require any additional communication aids?

Yes

20: Does the patient require any other additional support?
_{This may include hoisting, wheelchair access or bariatric care}

Yes

Section 5: Social workers and advocacy

22: Does the patient have a:

Social worker

Advocate

Neither

27: Is the patient subject to a child protection plan?

Yes

Unknown

28: Is the patient a Looked After Child?

Yes

29: Please enter any additional social information that you consider relevant.

Section 6: General Medical Practitioner

30: Does the patient have a general medical practitioner?

Yes

Section 7: Referrer details

35: Referrer full name

36: Referrer work address

37: Referrer work contact number

38: Referrer email address _{You will receive confirmation of receipt of this referral to the provided email address}

39: Referrer job role

Section 8: Clinical details

40: Reason for referral

Significant medical complexity

Learning disability

Specialist paediatric dental advice (including prevention and treatment planning)

Specialist special care advice including prevention and treatment planning

Severe mental health diagnosis

Bariatric patient (define)

Access to specialist equipment (such as wheelchair tipper, hoist)?

Domiciliary Care

Pre-cooperative for dental treatment

41: Please summarise the patient's concern 41b: Please summarise any treatment undertaken so far

42: How do you anticipate this patient will manage to undergo dental treatment?

Local anaesthetic

Inhalation sedation

General anaesthetic

Unsure

Section 9: Medical History

43: Please enter the patient's medical history. _{Please include any medications, allergies and named healthcare professions involved in care}

Section 10: Additional and supporting information

44: Referrals from dentists should have x-rays attached unless not clinically justified (eg. in the case of soft tissue lesions). Has the patient had any x-rays taken?

Yes

45: When were these x-rays taken? 46: Please upload x-ray file here (5Mb Max)

48: Is this referral part of an orthodontic referral for dental extractions?

Yes

49: Please upload the extraction request letter here.

50: Please enter any additional information that may be relevant.

Section 11: Declarations

50: Has the reason for referral been discussed?

Yes

51: Have you explained that patients who pay for dental treatment will have to pay or provide evidence of exemption?

Yes

52: Do you and the patient understand that this referral will only be accepted if the referral criteria have been met?

_{Our referral criteria guide is available here [Link]}

Yes

53: Is the patient aware that following completion of a treatment course, they will be discharged from our care?

_{In certain cases, patients may be seen in the community dental service as long-term patients, but this is not routine}

Yes

54: This patient has not been referred to any alternative dental care providers regarding their current concern

Yes

_{* All declarations must be confirmed before submitting referral.}

Northumbria Community Dental Services Referral

Section 1: Patient details

Section 2: Patient contact details

Section 3: Parent/carer/guardian contact details

Section 4: Communication and additional support

Section 5: Social workers and advocacy

Section 6: General Medical Practitioner

Section 7: Referrer details

Section 8: Clinical details

40: Reason for referral

42: How do you anticipate this patient will manage to undergo dental treatment?

Section 9: Medical History

Section 10: Additional and supporting information

Section 11: Declarations

50: Has the reason for referral been discussed?

51: Have you explained that patients who pay for dental treatment will have to pay or provide evidence of exemption?

52: Do you and the patient understand that this referral will only be accepted if the referral criteria have been met?

53: Is the patient aware that following completion of a treatment course, they will be discharged from our care?

54: This patient has not been referred to any alternative dental care providers regarding their current concern

Northumbria Community Dental Services Referral

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