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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.......