Referral checklist

Your details - name, address, telephone number and email address

Patient details - name, address, telephone number, date of birth, CHI number (or equivalent patient identification number)

Patient’s presenting complaint - if a young child, parent/carer’s concerns and expectations

Clinician’s concerns

• Why are you referring the patient?
• Is the referral urgent or routine?
• Has the child been in pain or had swelling?

Medical history – including current medications (and where applicable dosages, e.g. prednisone)

Dental history

• How anxious is the child about dental treatment? Include details of anxiety assessment (this might include a modified dental anxiety scale)
• What treatment has been attempted in this course of treatment before the referral was made?
• How has the child coped with treatment?
• Has local anaesthesia been used?
• Has the patient received sedation or general anaesthesia previously?
• Have antibiotics been prescribed in the past six months? (if so, type, dose, frequency)
• Does the child attend for scheduled care appointments?

Social history

• Who is the principal carer/legal guardian? Be mindful of the child’s social circumstances, and if necessary include details of who has parental rights for the child and how they can be contacted.
• Who does the child live with?
• What school or nursery does the child attend?
• Has the child received dental health home or community support or intervention from other agencies?
• If English is not the family’s first language, clearly state what language is spoken by the family so that an interpreter can be organised.

Summary of oral health status (e.g. caries and whether or not the child has good oral hygiene)

Details of your request

• Advice only.
• Care plan.
• Treatment by the referral service, but clearly indicate the care that you can provide locally e.g. prevention.

Enclosures 

• Details of any relevant records/correspondence (e.g. radiographs, study models, photographs, correspondence from orthodontist or other healthcare professional). 
• Include these with the referral. Failure to include relevant records/correspondence may result in your referral being returned or unnecessarily delay the patient’s assessment with the referral service.