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Referral form

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

Community dental

With effect from 12 March 2018

For General Dental practitioners wishing to refer a patient into the Community Dental Service this should be done via the DERS- Vantage REGO system. After this date all other electronic and paper referral systems will be no longer valid and the referral will be returned to referrer as per NHS England guidance.

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

Is this an urgent oncology referral? * required

Part 1 - About you (the referrer)
Are you a: * required

* required
* required

* required

* required
Part 2 - About the patient (being referred)
* required
* required
Gender: * required

* required
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* required

(if known)

(if different from part 1)

Is the patient over 21 stone in weight?

Does the patient require an interpreter? * required

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

Is your patient in foster care/needing LAC assessment?: * required
(please give details below)

Social workers name and contact details (box below)
Are you aware of any safeguarding issues surrounding the patients care?: * required
(please give details below)

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

Part 3 - For all referrers
Why can't this patient's treatment be provided in a general dental practice?: * required
(please check all that apply and give details below)

In your opinion:
Is the treatment urgent? * required

Is the patient suffering significant discomfort/pain/swelling? (that has not been resolved with temporary treatment or antibiotics)

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

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.

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