Referring to our service – East Sussex Healthcare NHS Trust

Person referring (Required)

General Practioner
Other health professional

Please specify (Required)

Referrer's details

Referrer's name (Required)

Last

Referrer's address (Required)

Referrer's email address (Required)

Referrer's telephone no. (Required)

Name of GP (Required)

Last

Address of GP (Required)

Patient details

Patient's name (Required)

Last

Patient's gender (Required)

Patient's NHS number

Patient's address (Required)

Patient's preferred telephone no. (Required)

Patient's email address

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

Special care dental service referral form

Referrer's details

Patient details

Domiciliary care

Dental care needs/dental history