Dental Service Domiciliary referral form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our Legal page. You can also read our privacy policy for more information.

Patient's name*
Title Firstname Surname
Patient's address*
Address line 1 Address line 2 Town County Postcode
Section 1 - Eligibility criteria for domiciliary oral healthcare
Please complete all sections and ensure that documents are signed to avoid delaying the referral process. If you require assistance completing any question(s) on this form please contact the Patient Care Co-ordinator on 0330 123 9438 who will be happy to assist.
Does the person attend his/her doctor?*
- Yes
- No
If the person has a hospital appointment, how does he/she get there?*
- Ambulance
- Taxi
- Car
Does the person have someone to bring them to the surgery?*
- Yes
- No
Does the person use a taxi for other activities?*
- Yes
- No
Mobility*
- Walks unaided
- Needs assistance
- Wheelchair user
- Confined to home
Section 2 - Personal details
Gender*
- Male
- Female
Date of birth*
NHS number
Phone*
Mobile
Email
Does the person / family / carer require an interpreter including BSL?*
- Yes
- No
Which language?*
Is there any history of violence or aggression from this person which we should be aware of?*
- Yes
- No
Do you have a risk assessment for this patient?*
Care plan or risk assessment required for patients that reside in a care/residential home.
- Yes
- No
Please upload risk assessment*
Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.
Are there any special access requirements or reasonable adjustments required to support this patient?
Are there any safeguarding issues regarding this person?*
- Yes
- No
Does this person suffer from dementia?*
- Yes
- No
Please include details of social services or care agency contact involved with this person
Section 3 - Accompanying documentation
Does the person hold an exemption certificate?*
- Yes
- No
If yes, please state which exemption is applicable (For guidance please see ‘Who is entitled to help with NHS dental Charges?’ section at end of form)
Expiry date*
Do you need to attach a medical history form?*
- Yes
- No
Upload medical history form
Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.
If the patient has a risk assessment or behaviour support plan in place, please attach to referral
Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.
Section 4 - Treatment required and reason for referral
Treatment required and reason for referral*
If referring for treatment relating to dentures please state whether or not the person has any natural teeth?*
- Yes
- No
Section 5 - Next of kin
Name*
Firstname Surname
Address*
Address line 1 Address line 2 Town County Postcode
Phone*
Mobile
Section 6 - Referrer's details
Referrer*
- I am the person / relative
- Healthcare professional
- Residential / Care home
Full name
Address*
Address line 1 Address line 2 Town County Postcode
Phone*
Section 7 - Confirmation
Signature*
Print name*
Medical history
Doctor's name and address*
Name Address Town County Postcode
Doctor's phone*
Height*
Weight*
Please tick if appropriate
- Learning disability
- Blind
- Deaf
Use makaton*
- Yes
- No
Medical questions
Have you ever been under the care of a doctor or hospital for any condition or due to be?*
- Yes
- No
Please give details*
Have you ever been hospitalised?*
- Yes
- No
Please give details*
Have you ever had an operation?*
- Yes
- No
Please give details*
Taking any prescribed medicines or recreational drugs (e.g. tablets, injections,inhalers or patches)?*
- Yes
- No
Please give details*
Had Covid-19 vaccine course?*
- Yes
- No
Please give details*
Carrying a warning card including steroid warning care?*
- Yes
- No
Please give details*
Pregnant or breastfeeding?*
- Yes
- No
Please give details*
A signed DNAR CPR (Do not attempt resuscitate order or Advance Directive?)*
- Yes
- No
If yes please show original to the dental team.
Allergies?*
For example, antibiotics, food, latex, chlorhexidine or other substances.
- Yes
- No
Please give details*
Been on oral, inhaled or topical steroids within the last year?*
- Yes
- No
Please give details?*
Have you ever had an adrenal crisis?*
- Yes
- No
Please give details*
Do you/the patient suffer/ever suffered from...*
- Heart troubles of any kind, for example, angina, heart attack, murmur or birth defect?
- High or Low Blood Pressure?
- History of rheumatic fever/infective endocarditis?
- Chest trouble, for example, asthma, COPD, TB, sleep apnoea or bronchitis?
- Stomach or Intestine problems, for example, reflux, hernia, Crohn’s?
- Liver problems or investigations, for example, hepatitis, jaundice (except at birth)
- Kidney or bladder problems, for example, decreased kidney fuction or surgery?
- Epilepsy, fainting or blackouts?
- Multiple Sclerosis, Parkinson’s Disease, Motor Neurone Disease, Alzheimer’s Disease, Stroke, Memory problems or similar condition?
- Diabetes?
- Hepatitis or jaundice, (except at birth)?
- Any infectious diseases, including HIV?
- Bleeding disorders?
- Anaemia/blood disorder, for example, B12 deficiency, sickle cell?
- Liver or kidney disease?
- Any infectious diseases including HIV, MRSA?
- Bone disorders such as osteoporosis?
- Any hormone imbalances, for example, thyroid, Growth, Cortisol?
- Cancer Treatment, for example, Chemotherapy, Radiotherapy, Surgery, Bisphosphonates?
- Hayfever or Eczema?
- Does anyone have health and wellbeing lasting power of attorney for you/the patient? If yes please provide details.
- Are there any behavioural fators or other information the dentist needs to know?
- None
Please add details
Have you (or the patient) had...*
- Allergies (e.g. antibiotics, food, latex or other substances)?
- Hayfever or eczema?
- Joint replacements, implant, artificial valve or pacemaker?
- Heart Surgery?
- Brain Surgery?
- Growth hormone treatment?
- Cancer treatment e.g. radiotherapy, chemotherapy, iv bisphosphonates?
- A close relative (parent, sibling or grandparents) with Creutzfeldt Jacob disease?
- A signed DNAR CPR (Do Not Attempt to Resuscitate) order
- None
Please add details
Please give us a list of medications you are taking and any further information that may assist us in treating you*
Are there any behavioural factors the dentist needs to know*
Are there any risk assessments in place for the patient?*
If yes, please ensure a copy is brought to any appointments.
Diet and tooth brushing habits
How often do you have sweets and or chocolate/fizzy drinks?*
- More than once a day
- Everyday
- 2-3 times a week
- Weekends only
- Very occasionally
Do you go to bed with a drink or drink in the night?*
- Water
- Plain milk
- Flavoured milk
- Squash
- Nothing
How often do you clean your teeth a day?*
- 0
- 1
- 2
- 3 or more
Do you use fluoride toothpaste?*
- Yes
- No
- Don't know
Drinking and smoking
Do you drink alcohol?*
- Yes
- No
How many units of alcohol do you drink per week?*
(A unit is half a pint of larger, a single measure of spirits or a single glass of wine/aperitif)
Do you smoke any tobacco products now or did you in the past?*
- Yes
- No
Do you chew tobacco, pan or supari now or did you in the past?*
- Yes
- No
Do you vape/ heat not burn tobacco now or in the past?*
- Yes
- No
Patient declaration
The remainder of this form must be completed by, or on behalf of, the patient.
I consent to the dental provider named above, or their representative, to examine me under the NHS and to give me any necessary care and treatment that I am willing to undergo within NHS arrangements. I agree to pay the statutory charges for the NHS dental service I receive, unless I have completed a valid claim for free or reduced cost NHS dental services below, and that I may have to pay the full amount prior to treatment. I agree, if necessary, to be examined and/or to have my dental records examined by the NHS Business Services Authority (NHSBSA) or other authorised bodies. I declare that the information I give on this form is correct and complete. I understand that if it is not, appropriate action may be taken against me.
Signature
Date
If you are signing for the patient give details below:
Name
Relationship to patient
To enable the NHS to prevent and detect fraud and mistakes, pay dentists and to secure the effective and efficient delivery of NHS and related services, relevant information on your NHS treatment may be shared with, and by the NHSBSA to NHS England, Department for Work and Pensions, HM Revenue & Customs, NhlS Digital, NHS Counter Fraud Authority, NHS Service Commissioners and bodies performing functions on their behalf. Your personal data will be deleted within 10 years of receipt into our systems. Further details are available at www.nhsbsa.nhs.uk/yqurinformation.
What is your ethnic group?
Contact details
Please provide your preferred method of contact below, as an alternative to your postal address.
Email
Phone
By providing this information, the NHSBSA may use this method to contact you to Number survey your NHS dentistry experience.
Claim for free or reduced cost NHS Dental Services
You must read this form before you sign it. Only sign if it is correct.
If you're not certain that you're entitled to receive free or reduced cost NHS dental services you MUST pay the dental practice. If you subsequently confirm that you were entitled to free or reduced cost dental services, you can claim a refund. If you have applied for a qualifying benefit or exemption certificate but have not received it yet, you must pay and claim a refund when/if you do receive it.

Checks on claims are undertaken to confirm you are entitled. Incorrect claims for free or reduced cost NHS dental services will result in a penalty charge of up to £100, in addition to the cost of NHS dental services. You won't have the opportunity to pay for the services first to avoid the penalty charge.
I am entitled to free NHS dental services because on the first day of treatment
- I am under 18 years of age.
- I am 18 years of age and in full time education
- I am pregnant
- I had a baby in the last 12 months
- I am currently in prison or a young offenders institution
Date baby due or born
I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of
- Income Support (Incapacity benefit and Disability Living Allowance does NOT count)
- Income-based Jobseeker's Allowance (Contribution-based does NOT count)
- Income-related Employment & Support Allowance (Contribution-related does NOT count)
- Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)
- Universal Credit (in the last assessment period there were no earnings, or earnings were within the allowed limit, please check at www.nhs.uk/healthcosts)
Hidden
OLD - I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of
- Income Support (Incapacity benefit and Disability Living Allowance does NOT count)
- Income-based Jobseeker's Allowance (Contribution-based does NOT count)
- Income-related Employment & Support Allowance (Contribution-related does NOT count)
- Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)
- Universal Credit (in the last assessment period there were no earnings, or earnings were within the allowed limit, please check at www.nhs.uk/healthcosts)
During the course of treatment these are the only benefits that entitle you to free NHS Dental Services.
I am entitled to free NHS dental services because I am named on one of the following certificates that is valid during the course of treatment
- HC2 Certificate
- NHS Tax Credit Exemption Certificate/Card (or entitled to one)
(You are not automatically entitled because you receive Tax Credits; there are qualifying conditions, please check at www.nhs.uk/healthcosts. If you qualify you will be sent an exemption certificate/card, but if you don't have one you can use the award notice as proof.)
I am entitled to reduced cost NHS dental services because
- I am named on a HC3 certificate that is valid during the course of treatment which limits the amount I have to pay to
Amount
Consent
Consent*
I confirm that the information I have given above is correct and complete and that I am entitled to free or reduced cost NHS dental services as above. I understand that I will have to pay for my treatment and a penalty charge of up to £100, if it is not correct and I am not entitled.*
Signature*
HD1 form
Once you submit this form you will be redirected to our HD1 payment form. If you fail to complete this form this will delay your referral being processed.

Please note, the form might take 20-60 seconds to submit, due to the length of the form. Do not refresh the page.

Recommended

Services

Pages

Leaflets

Dental Service Domiciliary referral form

Your information

Section 1 - Eligibility criteria for domiciliary oral healthcare

Section 2 - Personal details

Section 3 - Accompanying documentation

Section 4 - Treatment required and reason for referral

Section 5 - Next of kin

Section 6 - Referrer's details

Section 7 - Confirmation

Medical history

Medical questions

Diet and tooth brushing habits

Drinking and smoking

Patient declaration

Contact details

Claim for free or reduced cost NHS Dental Services

Consent

HD1 form