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Community Dental Referral form

Community dental - Referral form

Please give as much detail to support your referral as possible.

Thank you for referring to our Community Dental Service. We just wanted to make you aware of the extended waiting times for the Community Dental Service. This is due to the backlog of care being provided now that our service is face to face, but with reduced capacity access to ensure everyone is safe. Depending on the treatment required, patients could be waiting up to 12 months. We currently have limited access to General Anaesthetic and sedation facilities, due to the impact of Covid on our local hospitals. We are unable to provide endodontic treatment (root treatment ) under sedation.

Please ensure you provide as much information on your referral so we can prioritise care appropriately and accommodate as soon as possible .

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Is this an urgent oncology (cancer) referral? *Required

Is this an urgent oncology (cancer) referral?

Yes

Part 1 - About you (the referrer)

Are you a: *Required

Are you a:

General medical practitioner

Other health professional (please specify below)

If other, please specify:

First name: *Required

Last name: *Required

Practice address:

Telephone: *Required

Fax:

Email: *Required

Part 2 - About the patient (being referred)

First name: *Required

Last name: *Required

Gender: *Required

Gender:

Male

Female

Date of birth: *Required

Date / Date of birth

Address: *Required

Telephone (home): *Required

Telephone (work):

Mobile:

Hospital number/name: (if known)

NHS number:

Name and address of GP: (if different from part 1)

GP telephone:

Is the patient over 21 stone in weight?

Yes

If so, please add their weight:

Does the patient require an interpreter? *Required

Does the patient require an interpreter?

Yes

If yes, which language:

Does the patient have any special needs? (please tick all that apply and give details below)

Autism

Dental phobic

Learning disability

Medically compromised

Mentally compromised

Physically compromised

Trauma (specify below)

Armed Forces family

Other needs (specify below)

Please give details

Are you aware of any safeguarding issues surrounding the patients care? (please give details below) *Required

Are you aware of any safeguarding issues surrounding the patients care? (please give details below)

Yes

If yes, please give details

Does the patient have a social worker? *Required

Does the patient have a social worker?

Yes

Social workers name and contact details:

Are you aware of any risks associated with providing care for the patient? (please give details below) *Required

Are you aware of any risks associated with providing care for the patient? (please give details below)

Yes

Please give details:

Part 3 - About the issue

Please describe the dental problem the patient is experiencing. Please be as detailed as possible.

Why can't this patient's treatment be provided in a general dental practice? (please check all that apply and give details below) *Required

Why can't this patient's treatment be provided in a general dental practice? (please check all that apply and give details below)

ADHD

Autism

Dental phobia

Needle phobia

Other conditions which may affect behaviour

Specialist/special care dental treatment

Special needs already noted in part 2

Please give details:

Is the patient suffering significant discomfort/pain/swelling?

Yes

Any other details:

Has any treatment been attempted already? (such as antibiotic therapy or temporary measures)

Yes

Please give details

Please attach any additional information here (file types accepted - doc, docx, pdf, ppt, pptx, rtf, txt, xls, xlsx, jpg, jpeg, bmp, gif, png)

Attachment 1:

Attachment 2:

Attachment 3:

I agree to the privacy policy.

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By phone (general enquiries): 0300 123 3444

Via our customer experience team: MEDCH.customercare@nhs.net

Join our community forum: https://www.medwaycommunityhealthcare.nhs.uk/about-us/get-involved/community-forum

View our privacy notice: https://www.medwaycommunityhealthcare.nhs.uk/contact-us/privacy-notice

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