Northumbria Community Dental Services Referral

Section 1: Patient details

Patient title

Patient forname

Patient surname

Patient gender

Patient NHS number

Patient date of birth

Section 2: Patient contact details

Patient contact number _{Alternative contact number}

Patient address

Patient postcode

Patient email address

Section 3: Parent/carer/guardian contact details

Parent/carer/guardian full name

Parent/carer/guardian address

Parent/carer/guardian postcode

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

Section 4: Communication and additional support

Does the patient require an interpreter?

Yes

Does the patient require any additional communication aids?

Yes

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

Yes

Section 5: Social workers and advocacy

Does the patient have a:

Social worker

Advocate

Neither

Is the patient subject to a child protection plan?

Yes

Unknown

Is the patient a Looked After Child?

Yes

Please enter any additional social information that you consider relevant.

Section 6: General Medical Practitioner

Does the patient have a general medical practitioner?

Yes

Section 7: Referrer details

Referrer full name

Referrer work address

Referrer work contact number

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

Referrer job role

Section 8: Clinical details

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

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

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

Local anaesthetic

Inhalation sedation

General anaesthetic

Unsure

Section 9: Medical History

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

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

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

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

Yes

Please upload the extraction request letter here.

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

Section 11: Declarations

Has the reason for referral been discussed?

Yes

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

Yes

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

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

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

Reason for referral

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

Has the reason for referral been discussed?

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

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

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

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

Northumbria Community Dental Services Referral

Your referral submission is now complete.

Please click below to complete another referral or close this web page.