DESTINATION - Location the patient is being referred to (hospital/full name of practice):
ORTHO CODE
Patient's Name:
DOB:
Patient Address (inc postcode):
Male/Female:
NHS Number:
Parent name (if different):
Home Tel:
Mobile:
E-mail:
Name (block letters):
Practice Address (stamp acceptable on hard-copy forms):
GDC Number:
Main Tel. No:
Fax No:
GDP Details:
Medical and social history:
Allergies/sensitivities:
Previous dental trauma (specify):
Drugs/medications:
Teeth or poor long-term prognosis (specify):
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
Please Confirm:
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.......
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