REFERRAL FOR NHS ORTHODONTIC ASSESSMENT

Please complete this form for any patient in need of NHS orthodontic treatment that meets the following criteria:

  1. Patient to be less than 18 years of age at the point of referral (see guidance)
  2. Patient must meet the requirements of the Index of Treatment Need (IOTN) 4, 5 and 3 with an aesthetic component of 6 or above (SCAN) to be eligible for NHS treatment.
  • Please complete all sections of this referral form.
  • Please include a copy of an OPG (if available) – Please see Section Five

Please note that you must complete all sections of this form. If all sections are not completed, the form will be returned to you and the patients treatment will be delayed.

Please see accompanying notes for further details.

SECTION ONE – PATIENT DETAILS

Patient Name / Date of Birth
Address
Contact Tel(s):
Post Code
GP Name and Address

SECTION TWO – DETAILS OF REFERRER

Name of Referrer / Practice Stamp (Address and Contact Tel):
Signature
Date

SECTION THREE – REFERRAL HISTORY

Has this patient been referred before for NHS orthodontic treatment?
YES / No
If Yes, please specify where

SECTION FOUR – CHOICE OF PROVIDER

Has this patient or referrer expressed a preference of Provider?
Yes / No
If Yes, please provide details (who and why)
Please note: If the patient or referrer does not express a preference, the patient will be allocated to an appropriate Provider with capacity at that time. If the patient or referrer has expressed a preference this Provider may not be suitable and if the wait is above 18 weeks you may be contacted to discuss other alternatives.

SECTION FIVE – REASON FOR REFERRAL

Please provide below any additional information to support the referral
(please include the date of GDP appointment when possible need for orthodontic treatment identified)
OPG Enclosed (please tick)
Standard Referral / Second Opinion / Transfer of Care / Dispute

OFFICE USE ONLY:

CONTINUATION SHEET – PAGE 2 OF 2

Patient NameDate of Birth

CRITERIA - Please tick one box only. Start at the top and work down until you identify the component that best fits the patient being referred:

5i / Impeded eruption of teeth (excluding third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth & any pathological cause /
5m / Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties /
5a / Increased overjet greater than 9mm /
5h / Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics /
5c / Defects of cleft lip or palate and other craniofacial anomalies /
5e / Submerged deciduous teeth /
4h / Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for a prosthesis /
4a / Increased overjet greater than 6mm but less than or equal to 9mm /
4b / Reverse overjet greater than 3.5mm with no masticatory or speech difficulties /
4m / Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory and speech difficulties /
4c / Anterior or posterior crossbites with greater than 2mm discrepancy between retruded contact position and intercuspal position /
4l / Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments. /
4d / Severe contact point displacements greater than 4mm /
4e / Extreme lateral or anterior open bites greater than 4mm /
4f / Increased and complete overbite with gingival or palatal trauma /
4t / Partially erupted teeth, tipped and impacted against adjacent teeth /
4x / Presence of supernumerary teeth /

Please tick box for Dental Health Component & score between 1-10 for the Aesthetic Component (SCAN).

3a / Increased overjet greater than 3.5mm but less or equal to 6mm with incompetent lips / / scan
3b / Reverse overjet greater than 1mm but less than or equal to 3.5mm / / scan
3c / Anterior or posterior crossbites with greater than 1mm but less than or equal to 2mm discrepancy between retruded contact position and intercuspal position / / scan
3d / Contact point displacements greater than 2mm but less than or equal to 4mm / / scan
3e / Lateral or anterior open bite greater than 2mm but less than or equal to 4mm / / scan
3f / Deep overbite complete on gingival or palatal tissues but no trauma / / scan
Other Reason for Referral (e.g. Caries of doubtful prognosis) /

PLEASE SEND COMPLETED FORMS TO: Orthodontic Central Referral Centre, Fanshawe Wing, Level B, Royal South Hants Hospital, Brintons Terrace, Southampton, SO14 0YG OR FAX TO: 023 8063 8141.

Any queries please telephone: 023 8071 6695

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