Paediatric Dentistry Referral Form (15 years and under)

Paediatric Dentistry Referral Form (15 and below)

Date of referral*
Is this referral urgent?
- Yes
- No
Gender*
Date of Birth*
DD slash MM slash YYYY
NHS Number*
Patient Surname (family name)*
Patient Forename (first name)*
Patient address
Street Address Address Line 2 City/Town Borough Postcode
Contact telephone numbers*
Landline and mobile numbers are required. Please ensure these are up to date. These are what we will use to make first contact with your patient. Mobiles are used to send text reminders.
GP name*
Title Surname/family name Forename/first name
GP address
Street Address Address Line 2 City/Town Borough Postcode
GP telephone
Is an interpreter required?
- Yes - please specify language below
- No
Language
BSL interpreter required?
- Yes
- No
Medical History*
Please include any mobility/transport issues
Is the patient under hospital care for a medical reason?
- Yes
- No
If yes, which hospital?
List all medication*
Why are you referring this patient?*
Please include/attach charting of treatment required with an indication of urgency and/or severity such as recent pain or antibiotic use. The option to add attachments can be found at the end of this form. NB A failure to provide sufficient and legible information may lead to rejection of this referral.
How does the above patient meet the Paediatric Dentistry Referral Criteria?*
Please tick ALL relevant boxes
- Dental caries: likely GA (provide details below)
- Dental caries: other (expand below why referral should be accepted)
- Dental trauma: primary and permanent (expand under history)
- Opinion about poor quality molars (not RCT - consider obtaiing ortho opinion first)
- Complex medical or behavioural problems (expand below)
- Tooth surface loss e.g. erosion
- Dental anomalies: altered tooth structure, number, shape, size, form
- Disorders of tooth eruption and loss
- Surgical management e.g. unerupted teeth
- Periodontal problems
- Soft tissue conditions
- This is level 1 and appropriate for training purposes
- NB are there safeguarding concerns or is the child in the care of social services e.g. 'looked after' children (CLA). Please provide more details below.
Please provide more details about any safeguarding concerns:
Dental treatment provided:*
Please tick ALL relevant boxes
- Prevention including Fluoride varnish
- Radiographs (attach if available)
- Attempted local anaesthesia
- Restorations
- Other e.g. Hall crowns
- Unable to treat further (expand below)
Please expand on why you are unable to treat further:
Radiographs:
- Sent digitally
- Not possible
Name of referrer:*
Job title:
Organisation:
Address
Street Address Address Line 2 Town/City Borough Postcode
Telephone/mobile:
Secure email*
Please enter your email address:
Enter Email Confirm Email
Attachment (include image or x-ray)
Max. file size: 50 MB.
Attachment (include image or x-ray)
Max. file size: 50 MB.
Attachment (include image or x-ray)
Max. file size: 50 MB.
Attachment (include image or x-ray)
Max. file size: 50 MB.
I understand that this referral will not be accepted without completion of all sections of the form.

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