Please see reverse of form for guidance notes and where to send your referral. Please note that the latest information, guidance and electronic

forms are always available at www.dental-referrals.org

.

CHILD ORAL CARE REFERRAL (<16 YRS) Age of Patient in years: Patient’s Title & Name: Sex Date of Birth (DD/MM/YY)

/ / Patient’s Address:

Patient’s Town or City:

Preferred Contact No: Patient’s Postcode

Referrer’s Name: Practice Postcode: Date of Decision to refer / /

Interpreter required? Language? YES / NO

Practice Name and Address:

Practice Phone Number:

GDC Number: Care Type (Routine or Urgent) URN:

If Urgent Care please state why:

Patient’s School or Nursery Address [This information is essential and referrals will be rejected without it]

Patient’s GP Name and Address including Postcode:

Patient’s principle complaint: Previous dental history including experience with local anaesthetics

Main Reason for referral:

PAIN TRAUMA COMPLEX EXTRACTIONS UNRESTORABLE TEETH > 2 QUADRANTS

SWELLING UNDER 5’S MULTIPLE EXTRACT’S SOFT TISSUE PATHOLOGY PARAFUNCTIONAL HABITS

SUPERNUMARIES BEHAVIOURAL ISSUES DENTAL ANOMALIES COMPLEX ENDODONTICS (OPEN APEX)

INFECTION LEARNING DISABILITIES HYPODONTIA TOOTH SURFACE LOSS

IMPACTED TEETH ENAMEL / DENTINE DEFECTS DENTAL ANXIETY DISORDERS OF ERUPTION OR SHEDDING

BONE PATHOLOGY GAG REFLEX PERIODONTAL PROBLEMS BONE PATHOLOGY

TMJ ISSUES

PLEASE ENSURE THAT APPROPRIATE NATIONAL AND REGIONAL GUIDELINES HAVE BEEN MET. PLEASE ATTACH RADIOGRAPHS AS REQUIRED. SCHOOL OR NURSERY

INFORMATION IS FOR SAFEGUARDING

PLEASE CONFIRM BY TICKING BOX THAT ALL THE NECESSARY PREVENTION AND ADVICE INDICATED IN DELIVERING BETTER ORAL HEALTH HAS BEEN PROVIDED AND THAT CONTINUING CARE WILL BE OFFERED TO THE PATIENT IRRESPECTIVE OF THIS REFERRAL.

For extractions, please indicate below the teeth / roots to be removed with an X for caries indicate R or for endodontics indicate E

PERMANENT DENTITION 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

PRIMARY DENTITION E D C B A A B C D E

E D C B A A B C D E

Please describe why specialist care is required? Please state what attempts have been made to treat child in primary care? Must be completed

I have read and understood the guidance notes for referrals of this type (see details on reverse or at dental-referrals.org) SIGNED:

PLEASE COMPLETE A CHILD MEDICAL HISTORY FORM – COPY URN TO THIS FORM – ENSURE ALL BOXES ABOVE COMPLETED ADDITIONAL INFORMATION / LETTERS ETC MAY ACCOMPANY THE REFERRAL BUT MUST REFERENCE THE URN

PLEASE TEAR OFF THIS SECTION AND RETAIN FOR YOUR RECORDS.

PATIENT NAME REFERRED FOR URN

This a common medical history form. This should be used in combination with a referral form with an

URN.

CHILD (<16) MEDICAL HISTORY FORM

Before you begin a referral: Please ensure that you have read and understood the referral

guidelines; referrals not meeting these guidelines will be returned to you. Make sure that you have the necessary attachments, such

as radiographs, and, if this is an electronic form, that you have acquired a unique reference number (URN). You can read

guidelines, get a URN and check the status of any referral by visiting: www.dental-referrals.org.

DO NOT SEND A BLANK FORM – STATE NAD IN EACH BOX IF NECESSARY URN: PLEASE ENTER THE URN FROM THE REFERRAL FORM. THIS FORM SHOULD BE SUBMITTED WITH THE

REFERRAL FORM. ATTACH WITH A PAPER CLIP. PLEASE DO NOT STAPLE. MEDICAL ALERT – Please note here anything of particular importance in the medical history and their impact on delivering care within a regular primary care setting.

CARER – Please tell us if this patient will attend with a carer – please provide details of the carers contact details here:

DOES THE PATIENT HAVE / SUFFER FROM / CURRENTLY EXPERIENCING

NONE OF THE BELOW

BLOOD OR BLEEDING DISORDER

TAKING ANY PRESCRIBED / NON-PRESCRIBED MEDICATION

INFECTIOUS DISEASES (HEPATITIS)

PREGNANT OR POSSIBLY PREGNANT

LIVER DISEASE

ADHD – BEHAVIOURAL DISORDER

KIDNEY PROBLEM

COMMUNICATION PROBLEM

HEART MURMUR NOT DIAGNOSED AS INNOCENT

SKIN PROBLEMS

ANEMIA

ALLERGY (DESCRIB IN BOX BELOW)

OBESITY

PSYCHIATRIC DISORDERS

ONCOLOGY / CANCER – DESCRIBE TX

OTHER – PLEASE DESCRIBE BELOW

CARRYING A MEDICAL WARNING CARD OR BRACELET

HEART DISEASE

BRONCHITIS, ASTHMA OR OTHER CHEST COMPLAINT

PACE MAKER

CONGENITAL HEART DEFECT

VISUAL IMPAIRMENT

LEARNING DISABILITY

AUTISM

ENDOCRINE DISORDER

DIABETES

GASTROINTESTINAL DISORDER

EPILEPSY

NEUROMUSCULAR DISORDER

EATING DISORDER

SYNDROME – PLEASE SPECIFY BELOW

RECEIVING TREATMENT FROM HOSPITAL DOCTOR OR CLINIC

PLEASE PROVIDE DETAILS OF ANY CONDITION INDICATED ABOVE INCLUDING ASSESSMENT OF SEVERITY AND IMPACT ON DELIVERING CARE

MEDICAL ALERTS

EPILEPSY

DIABETES

ALLERGIES

STERIOD TREATMENT

SICKLE CELL ANEMIA

THALASSAEMIA

MEDICAL ALERT / BRACELET (DESCRIBE)

PLEASE LIST ANY ALLERGIES HERE MOBILITY ISSUES WALKS UNAIDED WALKS AIDED WHEELCHAIR USER

DESCRIBE WHAT ASSISTANCE IS REQUIRED:

IF CURRENTLY, OR PREVIOUSLY, UNDER HOSPITAL CARE, PLEASE STATE NAME OF PAEDIATRICIAN AND HOSPITAL ATTENDED

PLEASE PROVIDE DETAILS OF ANY PRESCRIBED MEDICINES HERE. YOU MAY ATTACH FURTHER DETAILS TO THIS FORM AS REQUIRED

 How to send your referral to us: Email us at:

d.referrals@nhs.net         Post your referral to: Dental Referral Management Centre 6 The Offices Stannian Fold, Pool Lane Lymm, WA13 9AB Fax your referral to: 0161 8502 123 For help, advice & support www.dental-referrals.org Phone support Please see website Please note that the fastest and most secure way to send your referral to us is via nhs.net email. Please contact your PCT to get an nhs.net email address. Please only fax referrals that have no attachments and do not send duplicate fax and postal referrals.

If you want PDF forms to complete electronically, or you need more forms simply visit the website and select referral tools. You will need a URN number for any referrals you are sending using your own printed or emailed forms. URNs are 10 digits and you can get up to ten at a time from the website.      Please talk to us. The best way to get immediate help and advice is to email us at office@dental-referrals.org. We will normally get back to you within a few hours. Cancer Referrals Please do not send any HSC205 referrals to our service. You can find details of how to refer suspected cancer cases at our website or from your PCT or local hospital trust.

PEADIATRIC REFERRAL NOTES & GUIDANCE

The Paediatric Units at local hospitals and CMFT Children’s Hospitals accept the following referral

types:

• Children with complex medical problems that may affect the provision of dental care.

• Children with developmental problems, learning difficulties and behavioural problems, who are unable to co-operate for routine dentistry.

• Children who have sustained complex dental trauma (e.g. pulp involvement in immature teeth).

• Children with congenital or acquired dental anomalies who may require complex restorative or orthodontic treatment (e.g. Hypodontia, Ameologensis Imperfecta, Dentinogenesis Imperfecta, Molar Incisor Hypominerisation, Micro / macro-dontia and delayed eruption).

• Children with soft or hard tissue pathology such as ulceration, swellings, and cysts.

• Children with non-contact tooth surface loss, requiring specialist intervention.

• Children with periodontal problems. • Children with cleft lip and palate and other cranio-facial

anomalies. • Supernumeraries, odontomes, impacted teeth,

submerging teeth, abnormal frenal attachments, and tongue-ties that may require surgical management.

• Pre-cooperative children who require extractions. • Children with extreme dental anxiety who have proven

unable to co-operate with routine dental treatment. Referrals are not accepted for:

• Routine primary care (e.g. caries in cooperative children, endodontic treatment in permanent teeth with closed apices).

• Root canal treatment in permanent molars unless there is good clinical indication for retention of the compromised tooth i.e. severe hypodontia.

• Routine (premolar) orthodontic extractions under GA.

Access to the Paediatric Dentistry GA or sedation services.

Referrals for extractions under General Anaesthesia or sedation, should follow the guidelines published by the GDC in Maintaining Standards. Guidance to Dentists on Professional and Personal Conduct. 1997; Paragraph 4.18; "Clear justification for the use of General Anaesthesia, together with details of the relevant medical and dental histories, must be contained in the referral letter". Further details, resources and information on the website. Inappropriate / inadequate referrals will be returned. Your compliance with the above guidelines will avoid unnecessary delays in patient care. Thank You.