Appendix 4 – Proforma for referring of patients (for clinical use)

See also:

Patient Triage System

To be completed by referring GDP, Clinical Triage Service or Urgent Dental Care system- for further information, see Appendix

Patient Name:


Contact details:


History of Presenting Complaint and/or previous treatment:

Previous Dental History (where applicable):

Relevant Medical History:

Examination Details (where applicable):



Radiographic Report (image included as available):


Treatment provided (copy of patient record can be included where applicable):

If prescription provided, include medication, dosage, duration and prescription number:

Review or further treatment required:


This form will be used to pass information in respect of patient care when any clinical advice or intervention takes place. Thus, the form can then be provided to the patient’s General Dental Practitioner, (where applicable) to be inserted within their clinical records. It is, therefore, important to maintain this form and all other associated forms in secure fashion and complete and pass on contemporaneously. All forms to be disseminated only by secure email using

Each completed form is to be saved with an appropriate file name, to include the patient’s name, date of birth and date of care provided before being sent onwards.

It is expected that only some sections will be completed, depending on circumstances. For example, a telephone consultation will result in limited details, whereas a video consultation will provide more information that can be appropriately sent onwards. If there are relevant radiographic images that can be included within this record, they should be attached appropriately within the body

It is expected that, if the patient has been provided advice and care within the Urgent Dental Care Service, this record will be more complete. It is important that all relevant information is captured, such that it can be conveyed on to the General Dental Practitioner (where applicable).

All records should also be saved by the treating clinician at each stage.

Where the patient does not have their own General Dental Practitioner, the Clinical Triager or Urgent Dental Care clinician is to retain this record within their own dental practice records and advise the patient that this has been done in the event that they then attend a dentist.