Dental Service Domiciliary referral form

Your information

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OLD INACTIVE Patient's name

Title Firstname Surname

OLD INACTIVE Title

Title(Required)

First name(Required)

Surname(Required)

Address line 1(Required)

Address line 2

Town(Required)

County(Required)

Postcode(Required)

OLD INACTIVE Patient's address

Address line 1 Address line 2 Town County Postcode

Section 1 - Eligibility criteria for domiciliary oral healthcare

Please complete all sections and ensure that documents are signed to avoid delaying the referral process. If you require assistance completing any question(s) on this form please contact the Patient Care Co-ordinator on 0330 123 9438 who will be happy to assist.

Does the person attend his/her doctor?(Required)

Yes

If the person has a hospital appointment, how does he/she get there?(Required)

Ambulance

Taxi

Car

Other

Does the person have someone to bring them to the surgery?(Required)

Yes

Does the person use a taxi for other activities?(Required)

Yes

Mobility(Required)

Walks unaided

Needs assistance

Wheelchair user

Confined to home

Section 2 - Personal details

Gender(Required)

Male

Female

Date of birth(Required)

NHS number(Required)

Find your NHS number.

Phone(Required)

Mobile

OLD INACTIVE Phone

OLD INACTIVE Mobile

Does the person / family / carer require an interpreter including BSL?(Required)

Yes

Which language?(Required)

Is there any history of violence or aggression from this person which we should be aware of?(Required)

Yes

Do you have a risk assessment for this patient?(Required)

Care plan or risk assessment required for patients that reside in a care/residential home.

Yes

Please upload risk assessment(Required)

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 2 MB.

Are there any special access requirements or reasonable adjustments required to support this patient?

Are there any safeguarding issues regarding this person?(Required)

Yes

Does this person suffer from dementia?(Required)

Yes

Please include details of social services or care agency contact involved with this person

Section 3 - Accompanying documentation

Does the person hold an exemption certificate?(Required)

Yes

If yes, please state which exemption is applicable (For guidance please see ‘Who is entitled to help with NHS dental Charges?’ section at end of form)

Expiry date(Required)

Do you need to attach a medical history form?(Required)

Yes

Upload medical history form

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 2 MB.

If the patient has a risk assessment or behaviour support plan in place, please attach to referral

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 2 MB.

Section 4 - Treatment required and reason for referral

Treatment required and reason for referral(Required)

If referring for treatment relating to dentures please state whether or not the person has any natural teeth?(Required)

Yes

Section 5 - Next of kin

Name(Required)

Firstname Surname

Address(Required)

Address line 1 Address line 2 Town County Postcode

Phone(Required)

Mobile

Section 6 - Referrer details

Referrer first name(Required)

Referrer surname(Required)

Referrer address line 1(Required)

Referrer address line 2

Referrer town(Required)

Referrer county(Required)

Referrer postcode(Required)

Referrer phone(Required)

Referrer secure email (.net or .gov)(Required)

OLD INACTIVE Referrer address

Address line 1 Address line 2 Town County Postcode

OLD INACTIVE Referrer

I am the person / relative

Healthcare professional

Residential / Care home

Section 7 - Confirmation

Signature(Required)

Print name(Required)

Medical history

Doctor's name(Required)

Doctor's address(Required)

Address line 1 Address line 2 Town County Postcode

OLD INACTIVE Doctor's name and address(Required)

Name Address Town County Postcode

Doctor's phone(Required)

Height(Required)

Weight(Required)

Please tick if appropriate

Learning disability

Blind

Deaf

Use makaton(Required)

Yes

Medical questions

Have you ever been under the care of a doctor or hospital for any condition or due to be?(Required)

Yes

Please give details(Required)

Have you ever been hospitalised?(Required)

Yes

Please give details(Required)

Have you ever had an operation?(Required)

Yes

Please give details(Required)

Taking any prescribed medicines or recreational drugs (e.g. tablets, injections,inhalers or patches)?(Required)

Yes

Please give details(Required)

Had Covid-19 vaccine course?(Required)

Yes

Please give details(Required)

Carrying a warning card including steroid warning care?(Required)

Yes

Please give details(Required)

Pregnant or breastfeeding?(Required)

Yes

Please give details(Required)

A signed DNAR CPR (Do not attempt resuscitate order or Advance Directive?)(Required)

Yes

If yes please show original to the dental team.

Allergies?(Required)

For example, antibiotics, food, latex, chlorhexidine or other substances.

Yes

Please give details(Required)

Been on oral, inhaled or topical steroids within the last year?(Required)

Yes

Please give details?(Required)

Have you ever had an adrenal crisis?(Required)

Yes

Please give details(Required)

Do you/the patient suffer/ever suffered from...(Required)

Please add details

Have you (or the patient) had...(Required)

Please add details

Please give us a list of medications you are taking and any further information that may assist us in treating you(Required)

Are there any behavioural factors the dentist needs to know(Required)

Are there any risk assessments in place for the patient?(Required)

If yes, please ensure a copy is brought to any appointments.

Diet and tooth brushing habits

How often do you have sweets and or chocolate/fizzy drinks?(Required)

More than once a day

Everyday

2-3 times a week

Weekends only

Very occasionally

Do you go to bed with a drink or drink in the night?(Required)

How often do you clean your teeth a day?(Required)

3 or more

Do you use fluoride toothpaste?(Required)

Yes

Don't know

Drinking and smoking

Do you drink alcohol?(Required)

Yes

How many units of alcohol do you drink per week?(Required)

(A unit is half a pint of larger, a single measure of spirits or a single glass of wine/aperitif)

Do you smoke any tobacco products now or did you in the past?(Required)

Yes

Do you chew tobacco, pan or supari now or did you in the past?(Required)

Yes

Do you vape/ heat not burn tobacco now or in the past?(Required)

Yes

Patient declaration

The remainder of this form must be completed by, or on behalf of, the patient.

I consent to the dental provider named above, or their representative, to examine me under the NHS and to give me any necessary care and treatment that I am willing to undergo within NHS arrangements. I agree to pay the statutory charges for the NHS dental service I receive, unless I have completed a valid claim for free or reduced cost NHS dental services below, and that I may have to pay the full amount prior to treatment. I agree, if necessary, to be examined and/or to have my dental records examined by the NHS Business Services Authority (NHSBSA) or other authorised bodies. I declare that the information I give on this form is correct and complete. I understand that if it is not, appropriate action may be taken against me.

Signature

Date

If you are signing for the patient give details below:

Name

Relationship to patient

To enable the NHS to prevent and detect fraud and mistakes, pay dentists and to secure the effective and efficient delivery of NHS and related services, relevant information on your NHS treatment may be shared with, and by the NHSBSA to NHS England, Department for Work and Pensions, HM Revenue and Customs, NHS Digital, NHS Counter Fraud Authority, NHS Service Commissioners and bodies performing functions on their behalf. Your personal data will be deleted within 10 years of receipt into our systems. Further details are available at www.nhsbsa.nhs.uk.

What is your ethnic group?

Contact details

Please provide your preferred method of contact below, as an alternative to your postal address.

Phone

By providing this information, the NHSBSA may use this method to contact you to Number survey your NHS dentistry experience.

Claim for free or reduced cost NHS Dental Services

You must read this form before you sign it. Only sign if it is correct.

If you're not certain that you're entitled to receive free or reduced cost NHS dental services you MUST pay the dental practice. If you subsequently confirm that you were entitled to free or reduced cost dental services, you can claim a refund. If you have applied for a qualifying benefit or exemption certificate but have not received it yet, you must pay and claim a refund when/if you do receive it.

Checks on claims are undertaken to confirm you are entitled. Incorrect claims for free or reduced cost NHS dental services will result in a penalty charge of up to £100, in addition to the cost of NHS dental services. You won't have the opportunity to pay for the services first to avoid the penalty charge.

I am entitled to free NHS dental services because on the first day of treatment

I am under 18 years of age.

I am 18 years of age and in full time education

I am pregnant

I had a baby in the last 12 months

I am currently in prison or a young offenders institution

Date baby due or born

I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of

Income Support (Incapacity benefit and Disability Living Allowance does NOT count)

Income-based Jobseeker's Allowance (Contribution-based does NOT count)

Income-related Employment & Support Allowance (Contribution-related does NOT count)

Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)

Universal Credit (in the last assessment period there were no earnings, or earnings were within the allowed limit, please check at www.nhs.uk)

OLD - I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of

Income Support (Incapacity benefit and Disability Living Allowance does NOT count)

Income-based Jobseeker's Allowance (Contribution-based does NOT count)

Income-related Employment & Support Allowance (Contribution-related does NOT count)

Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)

Universal Credit (in the last assessment period there were no earnings, or earnings were within the allowed limit, please check at www.nhs.uk/healthcosts)

During the course of treatment these are the only benefits that entitle you to free NHS Dental Services.

I am entitled to free NHS dental services because I am named on one of the following certificate that is valid during the course of treatment

HC2 Certificate

I am entitled to reduced cost NHS dental services because

I am named on a HC3 certificate that is valid during the course of treatment which limits the amount I have to pay to

Amount

Consent

Signature(Required)

Recommended

Services

Pages

Leaflets

Dental Service Domiciliary referral form

Your information

Section 1 - Eligibility criteria for domiciliary oral healthcare

Section 2 - Personal details

Section 3 - Accompanying documentation

Section 4 - Treatment required and reason for referral

Section 5 - Next of kin

Section 6 - Referrer details

Section 7 - Confirmation

Medical history

Medical questions

Diet and tooth brushing habits

Drinking and smoking

Patient declaration

Contact details

Claim for free or reduced cost NHS Dental Services

Consent

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