Special Care Dental Service (Page 2 of 2) in pdf

Special Care Dental Service Page 2

Have radiographs been taken ?

Yes

If ‘yes’ are they attached to this referral ?

Yes

Is this patient in unmanageable pain ?

Yes

Has the patient ever displayed any aggressive behaviour ?

Yes

If yes, please give details

Print name of

referring dentist

Referring Dentist Address

Practice Tel No

Date

Dentist Signature ___________________________

PATIENT/PARENT/LEGAL GUARDIAN

Please delete as appropriate:

I would be happy to accept an appointment at the clinic with the shortest waiting time

I would prefer to wait for an appointment at the clinic closest to my home

I confirm that I understand and agree with the reasons for this referral as discussed with

my dentist.

Signature _________________________________

Date

Relationship to patient __________________________Print Name_______________________

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

TRIAGE OUTCOME

(for SCDS use)

Date

Patient accepted for treatment

Patient does not meet any of the criteria for this service

Consider redirection of referral to MOS service (from PCT list)

Consider redirection to a sedation practice (from PCT list)

Incomplete referral form

Comments

If you have any concerns regarding this outcome please contact PCT Dental

Commissioners

Special Care Dental Service Page 2