ࡱ>  wbjbjupup 46:PP8T@L"w!w!w!HLJLJLJLJLJLJL$OQXnLw!U!"w!w!w!nLPPqL2U"U"U"w!XP8HLU"w!HLU"U"DH0K MY'!jtI$4LL<LIR9"RHKRKw!w!U"w!w!w!w!w!nLnLU"w!w!w!Lw!w!w!w!Rw!w!w!w!w!w!w!w!w! : SPECIAL CARE DENTISTRY REFERRAL FORM (16 YEARS OLD AND ABOVE)Surname:First Name(s):Gender:Male Female Prefer not to sayDate of Birth:NHS 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) Severe anxiety/phobia Mental health problems (severe) Complex medical conditions Domiciliary care required Bariatric (severely overweight) Homeless people, substance misuse Radiographs: Not possible Enclosed Sent digitallyWhat dental treatment and prevention strategies have already been provided?What dental treatment is required? What treatment modality is required? Behavioural management Local anaesthesia Inhalational sedation Intravenous sedation General anaesthesiaPlease record here any mobility / transport issues and relevant social history:  BRITISH DENTAL ASSOSCIATION CASE MIX TOOL Guidance on commissioning for Special Care Dentistry recommends that commissioners appraise themselves of the complex needs of patients this service. It can also assist in ensuring that the patient is seen by the most appropriate service. This validated Case Mix Tool is designed to measure patient complexity using six identifiable criteria applied to a weighted scoring system. Please assign a score for each criteria and add these together to give a total banded score: 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 8Legal and ethical barriersNone 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:Details of the NHS Special Care Dental Service where this referral is to be sent: I confirm that I have informed the patient / parent / carer that this form will be sent for triaging and may be forwarded to other appropriate NHS dental care providers. Signature: NHS 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)  NHS Treatment band1 2 3Patient charge Paid by patient Under 18 or 18 and in full time education. Pregnant or had a baby in the last 12 months. In possession of an HC2 NHS Certificate. An NHS 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. Universal Credit ON COMPLETION OF TREATMENT PLEASE DISCHARGE THE PATIENT TO: General Dental Practitioner Community Dental Service THIS REFERRAL WILL NOT BE ACCEPTED WITHOUT COMPLETION OF ALL SECTIONS REFERRAL / TRIAGE OUTCOME (this will be modified once preferred providers are identified) Date Referral Received: / /Date of Referral Triage: / /Triage undertaken by:NameJob TitleOUTCOME OF REFERRALACCEPTEDSuggested Provider: Level I (Training and Education) Level II (CDS) Level III (Acute Care)DECLINEDReasonsInsufficient Information with regards to:Patient detailsReasons for the referralRadiographsAbsent when stated enclosed / electronically transmittedInappropriate level of patient complexity to specific unitNo evidence that complexity of referral is appropriate to a Level II serviceNo evidence that complexity of referral is appropriate to a Level III service (try a Level II service)     TRIAGING ADMIN CODE (COMPLETED ON RECEIPT): The following on their own DO NOT entitle the patient to help with health costs: Incapacity Benefit Disability Living Allowance Pension Savings Credit Contribution Based Job Seekers Allowance NHS Prescription Charge Exemption Medical Exemption Certificate =>?_`ñyfWGWf7h h OJPJQJ\^JhbPhbPOJPJQJ\^JhbPhbPOJPJQJ^J$h hbPCJOJPJQJ^JaJ'hbPhbPCJOJPJQJ\^JaJ'h hbPCJOJPJQJ\^JaJh hbPOJPJQJ\^J#h hbPOJPJQJ\^JaJ$h h CJOJPJQJ^JaJ#h h OJPJQJ\^JaJ.h h 5OJPJQJ\^JaJmH sH >?HW_gPPPd$&`#$/Ifgd ~kd$$Ifl+|))      6` 0)64 lap ytQ$d$&`#$/Ifa$gd _`abhpiRR@@ & Fd$Ifgd d$&`#$/Ifgd kd$$Ifl4F |)` `     6`0)6    4 layt$p;$$d$&`#$/Ifgd kd$$Ifl4\  |)        6`0)64 layt  & Fd$&`#$/Ifgd Dkd$$Ifl4/F |)` `   6`0)6    4 laytbPd$IfgdbPd$&`#$/Ifgd 2kd$$Ifl4/\  |)     6`0)64 laytbP & Fd$Ifgd  & Fd$IfgdbP  $ - 9 : ; < = ] ~ $&`#$/Ifgd d$&`#$/Ifgd $d$&`#$/@&Ifgd # $ 8 = c ~  񻩚vgUA'hVh CJOJPJQJ\^JaJ"h h 5OJPJQJ\^JhVhbPOJPJQJ^Jh OJPJQJ^JhbPOJPJQJ^JhVOJPJQJ^Jh hVOJPJQJ^J#h h OJPJQJ\^JaJ$h h CJOJPJQJ^JaJh h OJPJQJ\^J$h h CJOJPJQJ^JaJh h OJPJQJ^J~  }fK0hd$&`#$/If^hgdbP & F d$&`#$/IfgdVd$&`#$/IfgdVkdq$$Ifl0|)[ 6`0)64 laytV G00d$&`#$/Ifgd kd!$$Ifl0|)[ 6`0)64 laytV & Fd$&`#$/Ifgd hd$&`#$/If^hgdV  > ?  3 4 5 Z vvvvbOvOv̆$h h CJOJPJQJ^JaJ'h h 5CJOJPJQJ^JaJh h 5OJPJQJ^J$h h CJOJPJQJ^JaJh hVOJPJQJ^JhOJPJQJ^JhVOJPJQJ^Jh OJPJQJ^Jh h OJPJQJ^J"hVh 5OJPJQJ\^J$hVh CJOJPJQJ^JaJ > ? 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