Name of Referrer: Date of referral: Job Title: Organisation Date received (office use): Address: Post code: Phone/Mobile: Secure Details of the NHS Special Care Dental Service 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 Under 18 or 18 and in full time education. 1 Treatment Pregnant or had a baby in the last 12 months. 2 band In possession of an HC2 NHS Certificate. 3 An NHS tax credit exemption certificate. Pension Credit Guarantee Credit. Patient £ Income Support. charge Income based Job Seekers Allowance. Income-related Employment & Support Allowance Paid by £ patient 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
Name of Referrer: Date of referral: Job Title: Organisation Date received (office use): Address: Post code: Phone/Mobile: Secure Details of the NHS Special Care Dental Service 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 band 1 2 3 Patient 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
Pan%20London%20Special%20Care%20Dentistry%20Referral%20Form.docx