Download Dentist Doctor Referral Note Template for Free

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NOTE: PLEASE ENSURE A CURRENT TREATMENT PLAN AND ALL RELEVANT X-RAYS ARE
ENCLOSED WITH THIS REQUEST FOR ASSESSMENT FORM. Please send/email referrals to;
SOUTH DEVON SPECIAL CARE DENTAL SERVICE,
CASTLE CIRCUS HEALTH CENTRE, ABBEY ROAD, TORQUAY, TQ2 5YH
Email sdc-dental.t-[email protected]
Patient’s details: (PRINT)
Patient’s Name
Patient’s Title
Mr / Master / Mrs / Miss / Ms
Sex
Male / Female
Home address
Postcode
Contact Telephone Number
Mobile Number
Date of Birth
NHS Number
Patient’s Doctor’s Name
Doctors Surgery
Name of Referrer (PRINT)
Name of Referring Surgery
Surgery Address & Postcode
(surgery stamp can be used)
Referrer Telephone Number
Practice Email Address
(NHS mail wherever possible)
Date patient last seen
Please tick reason for referral to Special Care Dental Service:
Learning disability [ ] Acquired brain injuries [ ]
Diagnosed mental health illness [ ] Autistic spectrum disorders [ ]
Current significant misuse of substances [ ] Child with cleft lip or palate [ ]
Dental treatment complicated by medical condition [ ]
Medical condition significantly affected by poor oral health [ ]
Sensory disability making access to general dental service difficult [ ]
Physical disability making access to general dental service difficult [ ]
Wheelchair user unable to transfer to dental chair (wheelchair platform required) [ ]
Access to bariatric chair needed [ ]
Uncooperative preschool children, children with a high level of anxiety or children with a phobia
of dental treatment (treatment must have been attempted in GDP first) [ ]
Dentist Doctor Referral Note Template
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