ࡱ>  bjbjR|R| 400L:PP8T@tM"G!G!G! M M M M M M M$O_RZ0MG!%!"G!G!G!0MPPqEM###G!RP8 M#G! M##H0nL{E('!^.J$L[M0MRJR!RHnLRnLG!G!#G!G!G!G!G!0M0M#G!G!G!MG!G!G!G!RG!G!G!G!G!G!G!G!G! : SPECIAL CARE DENTISTRY REFERRAL FORM (16 YEARS OLD AND ABOVE)Surname:First Name(s):Gender:Male Female Prefer not to sayDate of Birth: Number: Is this referral urgent? Yes NoHome Address: Post Code: Borough: Phone: Mobile contact:GP Name: GP Address: Post Code: Borough: Phone: Interpreter Required? Yes what language?  No Medical History (attach additional information as required) List all medication (attach additional information as required)How does the above patient meet the Special Care Dentistry Referral criteria? Learning disabilities (mod/severe) Physical disabilities (mod/severe) Mental health problems (severe) Complex medical conditions Frail Older person Domiciliary care required Bariatric (severely overweight) Homeless people, substance misuse Please tell us in detail why you are referring this person, and if possible use the complexity scores over the page : Please record here any mobility / transport issues  CASE MIX COMPLEXITY*Please tick the most appropriate score for each domain:CommunicationNo issues0Mild restriction 2Moderate restriction 4Severe restriction8CooperationFull cooperation 0Some difficulty 3Considerable difficulty 6Serious difficulty12Medical statusNo impact on care0Some impact 2Moderate impact 6Severe impact 12Oral risk factors Minimal risk0Moderate risk 3Severe risk 6Extreme risk 12Access to careUnrestricted0Moderately restricted 2Severely restricted 4Extremely restricted 8Mental Capacity issues None 0Some 2Mod 4Multi-professional consultation 8 TOTAL BANDED SCORE (ADD SCORES ASSIGNED AS ABOVE) Name of Referrer:Date of referral:Job Title :OrganisationDate received (office use):Address: Post code: Phone/Mobile Secure email:I confirm that I have informed the patient / carer that this form will be sent for triaging and may be forwarded to other appropriate dental care providers. Signature: Fees are charged for all dental treatment carried out by the Community Dental Services If the Patient intends to claim FREE or REDUCED cost Dental Care please indicate exemption criteria and advise the patient to bring proof to appointment. (Please note treatment may be deferred until evidence is provided) Under 18 or 18 and in full time education. Pregnant or had a baby in the last 12 months. In possession of an HC2 Certificate. An tax credit exemption certificate. Pension Credit Guarantee Credit. Income Support. Income based Job Seekers Allowance. Income-related Employment & Support Allowance HC3 certificate that limits the amount paid. 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