Special dental care referral form

This referral form is for GPs, community nurses or care workers

GPs (General Medical Practitioners) can refer to the special care dentistry department via ERS (electronic referral system) – which is preferred rather than the form below.

If you are a dentist, please use Vantage REGO to complete a referral. Referrals from dentists using this form will not be accepted.

Please note that this referral is for patients aged 16 or over - if you are looking to refer children or young adults under 16 please visit the paediatric dentistry page.

Referral date Required

Patient details

Patient title

Patient first name Required

Patient surname Required

Patient gender Required

Patient date of birth Required

Patient address Required

Address 1

Address 2

City

Country

County

Postal Code

Patient telephone number Required

NHS number (if known)

Patient email address

GP details

GP name Required

GP Surgery name Required

GP workplace telephone Required

GP work address Required

Address 1

Address 2

City

Country

County

Postal Code

Email address (@nhs.net if available)

Referrer details

Referrer name Required

Referrer telephone (work) Required

Referrer work address Required

Address 1

Address 2

City

Country

County

Postal Code

Referrer job title Required

Referrer email address (@nhs.net if available)

Carer details (if appropriate)

Carer name

Carer telephone number

Carer address

Address 1

Address 2

City

Country

County

Postal Code

Carer email (@nhs.net if available)

Patient medical history

Medical history - Please list all medical conditions, medications and allergies Required

Patient dental history

Reason for referral Required

Does the patient have a regular dentist? Required

What dental problem does the patient have or what dental treatment does the patient need? (Please email any radiographs to: dentalmaxillofacial.sash@nhs.net) Required

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Special dental care referral form

This referral form is for GPs, community nurses or care workers

Please note that this referral is for patients aged 16 or over - if you are looking to refer children or young adults under 16 please visit the paediatric dentistry page.

Patient details

GP details

Referrer details

Carer details (if appropriate)

Patient medical history

Patient dental history

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