Referrals

Patient Details

Practice Details

If you are referring for treatment, please complete section 1, 2, 3 and 4.

If you are referring for advice only, please complete section 1, 3 and 4, including all relevant information in section 3.

Referrals will be returned to you if all the relevant information on this form is not completed (*)

SECTION 1

Basic Information:

a. *Is the patient motivated to undergo orthodontic treatment (attend multiple treatments and wear an appliance)?
YESNO

b. *Is the oral health stabilised and the patient has oral hygiene acceptable for orthodontic treatment?
YESNO

c. *Have the patient and parents been advised that they may not be eligible for NHS treatment?
YESNO

d. *Is the patient in/very nearly in permanent dentition? Or state reason for early referral below.
YESNO

e. *Has the patient had bitewing radiographs taken in the last 6 months and any treatment completed
YESNO

Please do not refer for orthodontic treatment if you cannot tick ‘Yes’ against all of the above. You can still refer for advice (e.g.
extraction of decayed first permanent molars).

f. *Please complete a BPE**

g. *Are permanent canines erupted (Yes/No)?

h. *If not erupted, please indicate if palpable buccally / palatally / non-palpable

SECTION 2

This section must be completed if your referral is for treatment.

*You must be able to tick at least one of these boxes in order for your patient to qualify for treatment on the NHS.

Patients must be less than 18 years old on the date of assessment by the orthodontist to be eligible for NHS primary care treatment.

If complex secondary care is indicated the patient can be over 18 years of age – you must provide additional details and refer to the hospital service directly using this form.

Please complete additional information in Section 3 stating which teeth are missing. You may be asked to provide radiographs to determine if teeth are absent or impacted.

Other Clinical Features

Ectopic/impacted teeth requiring interventionCrossbites anterior or posterior with displacement greater than 2mmSevere Jaw DiscrepanciesCleft lip / palate or other craniofacial concern

*Please state your assessment of IOTN?

Details on IOTN scoring can be found on the LDI website where there is a simple guide to scoring as well as a copy of the aesthetic guidelines. DHC is scored from 1 – 5, Aesthetic from 1 through 10.

SECTION 3

Additional information

Tick if none

If you are referring a patient aged 18 or older this should be to the hospital service. The case must be multidisciplinary in nature and you must provide justification here or attach additional sheets

Please confirm that:

*The patient & parent / guardian understand NHS treatment is not guaranteed and will depend on need and assessment findings.
*The patient and parent / guardian understand what is involved in orthodontic care, what their responsibilities are and what commitment is required from them to complete orthodontic treatment.
*Please confirm that you have explained the above to the patient and parent/guardian and that they agree to comply.

Self Referral

Dentist Referral