London Special Care Dental referral form

If needed, please refer to the Special care dentistry referral guidance notes.

Patient details

Name*

First Last

Gender*

Male
Female
Prefer not to say

Date of birth*

NHS number*

Address*

Street Address Address Line 2 Town County Postcode

Phone*

Mobile

Is this referral urgent?*

Yes
No

BSL interpreter required?*

Yes
No

Which language?*

GP name

GP address

Street Address Address Line 2 Town County Postcode

GP phone

Medical history

Please attach additional information as required

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

List all medication

Please attach additional information as required

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

How does the above patient meet the special care dentistry referral criteria?*

Learning disabilities (mod/severe)
Physical disabilities (mod/severe)
Severe anxiety/phobia
Mental health problems (severe)
Complex medical conditions
Domiciliary care required
Bariatric (severely overweight)
Homeless people, substance misuse

Radiographs*

Not possible
Enclosed
Sent digitally

Attach radiographs

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

What dental treatment and prevention strategies have already been provided?*

What dental treatment is required*

What treatment modality is required?*

Behaviour management
Local anaesthesia
Inhalation sedation
Intravenous sedation
General anaesthesia

Please record here any mobility / transport issues and relevant social history

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London Special Care Dental referral form

Your information

Dental Service - London special care dental referral form

Step 1 of 3

Patient details

British Dental Assosciation case mix tool

Case mix complexity

Referrer details

Triage outcome