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Referral Form
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Standard Orthodontic Referral Form



    PATIENT

    REFFERING DENTIST/ORTHODONTIST

    If recent radiographic films exist (taken in the past year) hard copy images enclosed or alternatively send digital radiographs via NHS.net or attach and encrypted DVD or CD.
    Have radiographs been taken in the last year?: YesNo
    Radiographs enclosed?: YesNo

    YesNo Is the patient motivated to undergo orthodontic treatment (wear appliance)?
    YesNo Oral hygiene is good
    YesNo Is the patient caries at the time of referral?
    Malocclusion- you must indicate main feature otherwise the referral may NOT be accepted
    Decide if a malocclusion has an IOTN above 3.6 and then decide if referral should be to primary care or hospital using the following grid
    Feature

    Impacted or ectopic teeth

    Missing teeth (not 8s)

    Overjet

    Reverse overjet

    Lateral or anterior open bite

    Supernumerary teeth

    Submerging primary teeth

    Craniofacial anomalies

    Cleft lip and palate

    Complicating medical history

    Tooth structure anomalies

    Crossbites

    Crowding

    Primary care specialist services
    Mild
    One tooth missing in any quadrant
    <10mm
    Reverse overjet <3mm
    <4mm
    Erupted
    Primary care specialist services
    Moderate/severe
    More than one tooth Missing per quadrant
    >10mm
    Reverse overjet >3mm
    >4mm
    Unerupted
    Hospital service
    Referring practitioner signature.........
    Referring practitioner name.......
    Date.......