Dental domiciliary referral form

This is the referral form if a patient needs a domiciliary (home) visit. Please read all the referral criteria before submitting a form.

Referral criteria

Before referring a patient for domiciliary care, please ensure:

If the patient requires a home visit and is medically stable, able to co-operate and give consent, and/or lives in a residential care setting, they should be referred to Gentle Dental Care Mobile 44-46 Port Street Evesham WR11 1AW or email to angela.gibbons4@nhs.net Telephone number: 01386 570976
The patient is unable to leave their home for appointments such as GP, hairdresser, or hospital appointments without the need for ambulance transport.
If the patient does not meet the above criteria, but you feel they need to access the community dental service, then please read more on our web page.

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 domiciliary referral form

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