Nhs Clch Community Dental Referral Form
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1CLCH Community Dental Referral Form
Completed Forms to be returned to:
Postal Address:
Dental Office, Vale Drive Primary Care Centre, Vale Drive, Barnet EN5 2ED
Telephone Number:
0208 447 3623
Fax Number:
0208 447 3506
Patients Details:
Date of Referral:
Title
Forename (s)
Surname
D.O.B
Telephone
Mobile
DD
MM
YY
Address
Next of Kin
Ethnicity
Smoking
Status
School
Post Code
NHS No
Language
Spoken
Primary Carer
Reason for Referral: (Please see Referral Criteria for reference)
Physical Difficulties / Mobility Problems
Learning Disabilities
Significant Complex Medical History
Management Problems / Challenging Behaviour
Complex Social Needs
Complex Paediatric Dentistry
:
Further Details
Relevant Dental History: (Please note we do not accept patients who require orthodontic extractions/RCT only)
I confirm that I have advised the patient that the CLCH Community Dental Service does not offer emergency dental appointments to patients
before they have been assessed and accepted for treatment
Referrers Signature: ____________________________________
Referrers Details:
GP Details:
Your name
Patients GP
Practice name,
address &
GP Address
telephone no
Performer No.
GP Tel No
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Parent category: Medical