"*" indicates required fields Request typeReferral type * REQUIREDPlease choosePatient referral form (from a dentistry professional)Request for dental care/domiciliary (home) visit (from a health/social care professional or carer)Patient detailsName * REQUIRED MrMrsMissMsDrProf.N/A Title First Last Date of referral DD slash MM slash YYYY NHS No * REQUIREDGender * REQUIREDMaleFemaleOtherRather not sayDate of Birth * REQUIREDPlease note invalid digits that do not match the NHS digits will be ignoredPatient's address * REQUIRED Address Town / City / Village County Postcode Home phone * REQUIREDWork phoneMobile phoneEmail First languageIf not EnglishSchoolIf currently attendingContact person details (if different to patient)This person will be contacted to arrange dental careThe contact person is the:PatientParentGuardianNext of KinCarerKeyworkerContact person's name MrMrsMissMsDrProf.Rev. Title First Last Contact person's address Address Town / City / Village County Postcode Contact person's telephone numberReferrer detailsReferrer's name * REQUIRED MrMrsMissMsDrProf.Rev. Title First Last Referrer's job title * REQUIREDReferrer address * REQUIRED Address Town / City / Village County Postcode Referrer contactReferrer's email address * REQUIRED GP detailsIf not registered please type 'not registered' for all fields.GP's name * REQUIRED MrMrsMissMsDrProf.Rev. Title First Last Practice name / surgery * REQUIREDGP practice address * REQUIRED Address Town / City / Village County Postcode GP contactSocial Worker detailsDoes the patient have a Social Worker? * REQUIRED Yes No Social Worker's name * REQUIREDSocial Worker's telephone number * REQUIREDSocial Worker's email address * REQUIREDDetails of referralWhat treatment is required (please give details)Treatment attempted/completed (please give dates and treatments from the past)Please provide any supplementary information (please give dates and treatments from the past)Is this referral for a patient undergoing a private course of treatment? Yes No Medical history and patient-associated modifiersIntended referralTreatment/adviceMedical conditionsPlease click at least one * REQUIRED Behavioural, mental and neurological Blood/haematology Cancer/neoplasm Cardiovascular/circulatory Digestive system/gastroenterology Endocrine, nutritional and metabolic disorder Kidney/genitourinary Musculoskeletal/connective tissue Nervous system Respiratory system Other Select AllIf other, please specifyMedicationPlease specify all that apply Anticoagulants Bisphosphonate Immunosuppressive drugs Steroids Other If other, please specifySocial historyPlease specify all that apply Communication issues Cooperation issues Legal or ethical reasons affecting care Oral risk factors Restriction accessing care Does the patient have a severe gag reflect and/or severe dental anxiety/phobia? Yes No If yes, please specifyWould you like to add/upload any additional information? Yes No Additional informationPlease provide relevant supplementary informationImaging informationUpload X-ray/clinical illustration (obligatory) or explanation why the X-ray could not be sentRadiographs Yes No If no please give reason in more information below.File uploadMax. file size: 64 MB.Accepted file types: jpg, png, gif, pdf, docx, Max. file size: 12MBFile upload Drop files here or Select files Max. file size: 64 MB. Accepted file types: jpg, png, gif, pdf, docx, Max. file size: 12MBPlease note: Please include as much information as possible to enable the urgency of this referral to be assessed. If you wish to discuss your referral with a senior clinician, please call the dental clinic on 0300 421 6440. The Community Dental Service will only accept patients who meet the criteria for Special Care Dentistry - there is no guarantee this patient can be accepted for care. After the referral has been triaged, if the patient is accepted, they will be placed on a waiting list for an initial assessment either by telephone or appointment as appropriateBased on current guidelines, GCS Dental Service is unable to accept children requiring general anaesthesia for orthodontic extractions unless the treatment plan includes the removal of permanent molar teeth. These cases will still be assessed on an individual basis. GCS Dental Service does not carry out conservation of children’s teeth under GA (unless there is a special care need) and, in line with the guidance from the British Society of Paediatric Dentistry, it should be explained to carers of all referred children that undergoing a GA would usually indicate radical extractions of all decayed teeth so that further GA’s may be prevented in the future. It is the responsibility of referring dentist to continue to provide both Preventive and Urgent care until we are able to see the patient. If you wish to discuss your referral with a Senior Clinician, please call the Dental Clinic on 0300 421 6440. After the referral has been triaged, if the patient is accepted, they will be placed on a waiting list for an initial assessment appointment. The Community Dental Service will only accept patients who meet the criteria for Special Care Dentistry - there is no guarantee this patient can be accepted for care.Reason why X-ray/clinical illustration can't be sentConsent * REQUIRED I have patient consentI confirm that the patient (and/or carer/parent/guardian) has the capacity and is willing to make a voluntary and informed decision to consent to this referral being made and shared as necessary with those working for or on behalf of NHS England & NHS Improvement with all relevant providers.CAPTCHANameThis field is for validation purposes and should be left unchanged.