Please return to the Referral Management Centre
Somerset Primary Care Dental Service
Referral for Dental Care for Patients with Additional Needs
Referral Form B
NB Please use Form A to refer for surgical procedures
See telephone 01278 411630for more information
To be completed by the referring Dentist:Please circle below the most convenient location for the patient to attend and return to the Referral Management Centre, Ground Floor, Mallard Court, Express Park, Bridgwater TA6 4RN, in the envelope supplied. / TAUNTONYEOVIL
MINEHEADCHARD
WELLINGTONGLASTONBURY
BRIDGWATERWELLS
BURNHAM-ON-SEAFROME
Name and Address of Referring Dentist / PATIENT DETAILS Mr/Miss/Mrs/Ms
Telephone / First Name
Surname
Address
Postcode
Name and Address of Doctor / Date of Birth / Male/Female / First Language if not English
Telephone
Home Tel No / Work/Mobile Tel No.
Reasons for referral
Treatment requested
Describe previous attempts at treatment
Radiographs are required for patient assessment. Please ensure all relevant and other recent radiographs are enclosed
Xrays enclosed / DPT / Intra Orals / None (reason)
CONFIDENTIAL MEDICAL HISTORY FORM
Please tick Yes/No giving any relevant details / No / Yes / If ‘Yes’ please give details:Has the patient ever had a general anaesthetic?
If YES, where, when and what for?
Has the patient suffered from any of the following?: If YES, please give details
Heart conditions
Diabetes
Allergies, e.g. hayfever
Fits or convulsions
Fainting or blackouts
Bleeding problems
Jaundice
Asthma, bronchitis or any other chest complaint
Any other serious illness
If YES please specify
Does the patient smoke?
Is the patient pregnant?
Is the patient allergic to penicillin or any other drugs or medicine?
If YES, please give drug name
Please list in this box any medications the patient is taking and what illnesses they are for.
Please ensure the checklist below is complete: Please Tick
The above referral has been discussed and agreed with the patient and/or Parent/Guardian
I understand that the final decision for treatment offered rests with the PCDS Dental Officer following discussions with the patient/parent. When appropriate, consultation with the General Dental Practitioner will be undertaken
I understand that NHS charges are payable to PCDS unless the patient is exempt and that NHS charges have only been raised for treatment already carried out.
Please enclose a Personal Treatment Plan form FP17RN. Charges will be payable for work carried out by PCDS.
If your referral does not meet the Primary Care Dental Service criteria or if this form is not legible or completed fully, we reserve the right to return it to you.
Dentist’s Signature / Print Name / GDC Number / Date
PCDS Admin only:
Triage1:
DAC: / Referral form reviewed by: / Accepted/Rejected, reason if rejected
Priority (1,2,or3) / Date: / Comments
PCDS Admin only:
Triage 2:
DAC: / Referral form reviewed by: / Accepted/Rejected, reason if rejected
Priority (1,2,or3) / Date: / Comments
Please return to theReferral Management Centre, Ground Floor, Mallard Court, Express Park, Bridgwater TA6 4RN, in the envelope supplied.