SECTION 4 – PATIENT PARENT/GUARDIAN, SCHOOL SECTION 3 – FULL PATIENT DETAILS NURSE OR CARER DETAILS (if applicable) Mr Mrs Miss Ms Dr Other Mr Mrs Miss Ms Dr Other Male Female NHS Number: Relationship to patient: Surname: Surname: First name: First name: Date of Birth: Date of Birth: Address: Address: Town/City: Town/City: Postcode: Postcode: Telephone Number: Telephone Number: Work Number: Work Number: Mobile Number: Mobile Number: E-mail Address: E-mail Address: SECTION 5 - REFERRER DETAILS SECTION 6 - PATIENT GP DETAILS (if not the referrer) Mr Mrs Miss Ms Dr Other Mr Mrs Miss Ms Dr Other Surname: Surname: First name: First name: Job Title: Practice Name: GDC/GMC Number: Practice Address: Practice Name: Practice Address: Town/City: Postcode: Town/City: Telephone Number: Postcode: E-mail Address: Telephone Number: E-mail Address: SECTION 7 - COMMUNICATION & SPECIAL REQUIREMENTS Does the patient communicate in a language or mode other than English? YES , please detail. NO Is an interpreter required? YES , please detail. NO Does the patient have any special requirements? YES , please detail. NO SECTION 8 - PATIENT CONSENT TO REFERRAL AND ASSOCIATED TREATMENT Has the patient understood and consented to the referral? YES NO SECTION 9 – CONFIRMATION AND SIGNATURE OF REFERRING PRACTITIONER I confirm that this patient referral meets the current referral guidelines as issued by the Bristol Dental Hospital. (Referral guidelines are available on the BDH website). I understand that incomplete and/or inappropriate referrals will be returned for revision and may delay patient treatment. Please tick to confirm. Print Full Name:………………………………………………………………………………………………… Date:…………………………................. Signature: ……………………………………………………………………………… Please return fully completed forms to: Patient Access Team, Bristol Dental Hospital, Chapter House, Lower Maudlin Street, Bristol, BS1 2LY. Fax: 0117 342 4994. Call Centre Tel: 0117 342 4422.
SECTION 3 – FULL PATIENT DETAILS SECTION 4 – PATIENT PARENT/GUARDIAN, SCHOOL NURSE OR CARER DETAILS (if applicable) Mr Mrs Miss Ms Dr Other Male Female NHS Number: Surname: First name: Date of Birth: Address: Town/City: Postcode: Telephone Number: Work Number: Mobile Number: E-mail Address: Mr Mrs Miss Ms Dr Other Relationship to patient: Surname: First name: Date of Birth: Address: Town/City: Postcode: Telephone Number: Work Number: Mobile Number: E-mail Address: SECTION 5 - REFERRER DETAILS SECTION 6 - PATIENT GP DETAILS (if not the referrer) Mr Mrs Miss Ms Dr Other Surname: First name: Job Title: GDC/GMC Number: Practice Name: Practice Address: Town/City: Postcode: Telephone Number: E-mail Address: Mr Mrs Miss Ms Dr Other Surname: First name: Practice Name: Practice Address: Town/City: Postcode: Telephone Number: E-mail Address: SECTION 7 - COMMUNICATION & SPECIAL REQUIREMENTS Does the patient communicate in a language or mode other than English? YES , please detail. NO Is an interpreter required? YES , please detail. NO Does the patient have any special requirements? YES , please detail. NO SECTION 8 - PATIENT CONSENT TO REFERRAL AND ASSOCIATED TREATMENT Has the patient understood and consented to the referral? YES NO SECTION 9 – CONFIRMATION AND SIGNATURE OF REFERRING PRACTITIONER I confirm that this patient referral meets the current referral guidelines as issued by the Bristol Dental Hospital. (Referral guidelines are available on the BDH website). I understand that incomplete and/or inappropriate referrals will be returned for revision and may delay patient treatment. Please tick to confirm. Print Full Name:………………………………………………………………………………………………… Date:…………………………................. Signature: ……………………………………………………………………………… Please return fully completed forms to: Patient Access Team, Bristol Dental Hospital, Chapter House, Lower Maudlin Street, Bristol, BS1 2LY. Fax: 0117 342 4994. Call Centre Tel: 0117 342 4422.
5a._special_care_referral_form_v1.2.docx