Patient Details

Name *

Please specify your gender *

Date of Birth *

Address *

Postcode *

Telephone Number *

Mobile Number

Email Address *

NHS Number

Ethnicity

Parent/Guardian/Carer Name *

Relationship to patient

Has the patient consented to information sharing with other healthcare professionals where necessary? *

Yes

Referrer Details

Are you referring from: *

General Dental Practitioner Other health, education or social care profession

General Medical Practitioner

Name *

Job role *

Address *

Postcode *

Email Address *

Telephone Number *

Are you a learning disability nurse? *

Yes

Does the patient have a VIP passport and behavioural plan? *

Yes

Please attach if available Upload file

Safeguarding

Are there are safeguarding concerns that you aware of regarding this patient? *

Yes

Please specify *

Does the patient present any challenging behaviour? *

Yes

Please provide details, including whether the patient has ever hurt themselves or others, or damaged any property/equipment as a result of this behaviour *

Is this patient or family receiving help or support from a social worker? *

Yes

Social worker name *

Social worker job title *

Social worker telephone number *

Social worker email *

Mobility and Communication

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

Which language? *

Tick the relevant boxes *

Hoist required Domiciliary/home visit required

Wheelchair user None applicable

Please specify any other needs or communication needs that may be helpful for us to know about this patient or their parent/carer? *

Please note we have a strict triage in place for requests for home visits. We are limited to what treatment can be provided. If the patient is able to leave their home it is safer to receive their treatment in the dental surgery.

Please note that we have a strict triage in place for requests for home visits. We are limited to what treatment can be provided and only provide one course of treatment. Once treatment has been completed, the patient will require a new referral, if our services are still required. If the patient is able to leave their home, it is safer to receive their treatment in the dental surgery.

Dental Referral Form UPDATED