Special Care Dental Service
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2SPECIAL CARE DENTAL SERVICE
Patient Referral Form – for use by General Dental Practitioners
Patients of any age with special needs who meet the service acceptance criteria will be
considered. All sections of this form must be fully completed to avoid unnecessary delays and
incomplete forms will be returned. An electronic version is available on request.
The referring GDP remains responsible for emergency care until the patient is seen for their first
appointment.
Once completed please send this form to :
Clinical Director, Special Care Dental Service, The Red House, Harpenden Memorial Hospital, Carlton Road,
Harpenden, AL5 4TA
Tel: 01582 714195/714190
Fax: 01582 713657
SECTION 1- Acceptance Criteria
The patient being referred is a Hertfordshire resident who :
please tick
♦
Is a wheelchair user unable to transfer to the dental chair without the use of a hoist
Has a diagnosed moderate/severe learning disability who cannot be managed in
♦
General Dental Practice
Has a diagnosed moderate/severe mental health problem who cannot be managed in
♦
General Dental Practice
Has a complex medical condition not manageable in General Dental Practice
♦
Please give details :
SECTION 2 – Patient details
Title
First name
Surname
Date of Birth
NHS number
Address
Post Code
Daytime Tel No.
Mobile Tel No.
Does this patient need an interpreter ?
YES
NO
If ‘Yes’ which language would be required :
SECTION 3 – Treatment detail
Has treatment been attempted ?
Yes
No
Please give details of treatment attempted
Please give details of treatment requested
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Parent category: Medical