Referral form for adults with dental anxiety | Herefordshire and Worcestershire Health and Care NHS Trust

Dental anxiety - adults referral form

This is the referral form for dental care for adults with dental anxiety. Please read all the referral criteria before submitting a form.

Referral criteria

We recommend that anxious adult patients be referred by their general dental practitioner (GDP), as they can tell us what treatment the patient needs and any previous interventions.

All dentists learn simple ways to help nervous patients. We are here for people who need more support such as:

Adults aged 16 and over who are too anxious or afraid to have dental treatment and have had failed treatment attempts before by their own GDP.
Meet the threshold score for the Modified Dental Anxiety Scale (MDAS).
Do not have additional complex or serious medical conditions - please refer them as a special care adult.

We cannot accept referrals for:

Patients not meeting the threshold for required MDAS score.
Requiring just a scale and polish.
Requiring root canal treatment.
Requiring cosmetic/ aesthetic dentistry.
Requiring General aneasthesia.

Please complete this form as fully as possible. There is no back button and you won’t be able to return to it once you press submit.

Patient acceptance criteria

Note: Questions marked by * are mandatory

*This is a mandatory field. Are you a general medical practitioner or other healthcare provider?

General medical practitioner
Other healthcare professional

*This is a mandatory field. Your job title

*This is a mandatory field. Professional registration number

*This is a mandatory field. Organisation and full address

Email address

*This is a mandatory field. Phone number

*This is a mandatory field. As well as the criteria above, why are you referring the patient to the service?

Adults aged 16 and over who are too anxious or afraid to have dental treatment
Adults who have had failed treatment attempts before by their own general dental practitioner
Adults who meet the threshold score for the Modified Dental Anxiety Scale and Index of Sedation Need
Adults who do not have additional complex or serious medical conditions

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Dental anxiety - adults referral form

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Dental anxiety - adults referral form

Referral criteria

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