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Home > Our services > Special Care Dental Service > Referring to our service

In this section

Special Care Dental Service
- Referring to our service

Referring to our service

Special Care Dental Service

In this section

Special Care Dental Service
- Referring to our service

We take referrals from various healthcare professionals.

General Dental Practitioners
General Medical Practitioners
Health and Social care professionals
Hospital, Oral and Maxillofacial Unit doctors and dentists

General dental practitioners must refer using an electronic referral system called Rego.

General Medical Practitioners and other Healthcare Professionals can use this form or use our online form below.

Patients cannot self-refer to this service.

Special care dental service referral form

Person referring (Required)
- General Practioner
- Other health professional
Please specify (Required)
Referrer's details
Referrer's name (Required)

Prefix

First

Last
Referrer's address (Required)

Address

Town/city

Postcode
Referrer's email address (Required)

Enter Email

Confirm Email
Referrer's telephone no. (Required)
Name of GP (Required)

Prefix

First

Last
Address of GP (Required)

Address

Town/city

Postcode
Patient details
Patient's name (Required)

Prefix

First

Last
Patient's date of birth (Required)
Patient's gender (Required)
Patient's NHS number
Patient's address (Required)

Address

Town/city

Postcode
Patient's preferred telephone no. (Required)
Patient's email address

Enter Email

Confirm Email
Name of parent/guardian/carer

First

Last
Name and relationship of lasting power or attorney/next of kin

First

Last

Suffix
Full medical history
(patient record summary preferable)
Medication
Exempt from dental charges (Required)
- Yes (exemption status must be evidenced. An incorrect declaration can result in a fine)
- No
Please state exemption
You are entitled to free dental treatment if you are:

- aged under 18, or under 19 and in qualifying full-time education
- pregnant or have had a baby in the previous 12 months
- Income Support
- Income-related Employment and Support Allowance
- Income-based Jobseeker's Allowance
- Pension Credit Guarantee Credit
- Universal Credit and meet the criteria

If you are entitled to or named on:

- a valid NHS tax credit exemption certificate - if you do not have a certificate, you can show your award notice; you qualify if you get Child Tax Credits, Working Tax Credits with a disability element (or both), and have an income for tax credit purpos-es of £15,276 or less
- a valid HC2 certificate

People named on an NHS certificate for partial help with health costs (HC3) may also get help.

You will not be exempt from paying dental charges because you receive any of the following:

- Incapacity Benefit
- contribution-based Employment and Support Allowance
- contribution-based Jobseeker's Allowance
- Disability Living Allowance
- Council Tax Benefit
- Housing Benefit
- Pension Credit Savings Credit
- Personal Independence Payment

Medical conditions do not exempt patients from payment for dental treatment. You'll be asked to show your dentist written proof that you do not have to pay for all or part of your NHS treatment. You will also be asked to sign a form to confirm that you do not have to pay.

Exemption for pregnant women

Pregnant women and women who have had a baby in the last 12 months get free NHS dental treatment. You may have to show proof, such as a maternity exemption certificate (MatEx), a maternity certificate (MATB1), or your baby's birth certificate.

If you gave birth more than 12 months ago, you will not be entitled to free NHS dental treatment. The MatEx only gives exemp-tion from NHS prescriptions.
Referral critieria (Required)
- Adults and children who require treatment under general anaesthetic
- Autistic Spectrum Disorders (please give details below)
- Children on child protection plan or from homeless families
- Complex medical history/disabilities (please give details below to support severity threshold)
- Complex/severe mental illness (please give details below to support severity threshold)
- Domiciliary visit
- Learning Disability (please give details below)
- Severe physical disabilities (please give details below)
- Traveller children
What additional needs does the patient have that requires special care dentistry?
Domiciliary care
Does the patient attend any other appointments
- Yes
- No
How do they get to them?
Does the patient leave the home for any other reasons
- Yes
- No
Please explain why the patient is housebound
Dental care needs/dental history
Please detail any significant dental history or care received
I confirm I have advised the patient that: (Required)
- If patient contact details change these must be updated by the patient through the referrer
- The Special Care Dental Service will assess if the patient meets the referral criteria
- Not all patients will remain under the care of the service
- If a patient fails to attend they may be discharged
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