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Working with you, for you Special Care Dental Service Jan 2016
Please give information explaining chosen category:
Overview of patient’s medical history (please complete & sign the Special Care Dental Service medical
history form and include a list of the patient’s current medication with the referral):
Dental Treatment plan for patient: Please attach Personal Dental Treatment plan form FP17DC
Outline of recent dental history / treatment attempted:
CHECKLIST Please ensure the following is enclosed / agreed:
Recent relevant X-ray emailed to sdc-dental.t-[email protected] (from NHS email account) [ ]
Signed Special Care Dental Service medical history form enclosed [ ]
Personal Dental Treatment plan form FP17DC enclosed [ ]
Patient has been informed of request for assessment and the reason for referral [ ]
Referral is made in line with Delivering Better Oral Health, GDC Standards and is in the patient’s best interest [ ]
We will devise the patient’s final treatment plan, do you wish to be informed of these changes before we proceed?
(please note if yes this may delay the patients treatment) Yes [ ] No [ ]
Do you consider this to be an urgent referral? If yes please state why: Yes [ ] No [ ]
Please note:
The Special Care Dental Service in Torbay does not carry out conservation of children’s teeth under GA 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 teeth as necessary so that
further GA’s may be prevented in the future.
The Special Care Dental Service reserves the right to refer patients back to their General Dental
Practitioner if they do not fit any of the criteria the service is commissioned to provide, or if the form is
not legible or completed fully.
Date of referral
Carious teeth
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