Appendix 4 – Proforma for referring of patients – Patient Triage System Care Record

See also:

This Patient Triage System Care Record must be completed by the referring GDP, the Clinical Triage Service and by Urgent Dental Care System.

Information on How to Complete Patient Triage System Care Record

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.

Patient Triage System- Care Record

Patient Name

Patient DOB

Patient Address (including postcode)

Patient Contact Number


Clinician’s Name:

GDC Number:



Patient Complaint:

History of Presenting Complaint and/or previous treatment:

Details of Patient’s GDP:

Previous Dental History (where applicable):

Medical History:


Examination Details (where applicable):



Radiographic Report (image included as available):


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

Has a prescription been provided? If yes include medication, dosage, duration and prescription number:

Outcome – onward referral? Review required? Further treatment needed?