ORTHODONTIC REFERRAL FORM for Patients with IOTN 3.6 Or Above Who Have Never Started A

ORTHODONTIC REFERRAL FORM for patients with IOTN 3.6 or above who have never started a course of treatment, except when < 10 years old

Patients Details / NHS number
Name / Date of birth / Sex MF / Age 0
Address 1 / Tel
Address 2 / Mobile
Town
/ postcode / Email
Referring Practitioner Details
Name / Tel
Practice Name / Mobile
Address / Email NHS
Town / postcode / Exam date

Clinicians who are trained in IOTN may complete parts A,B or D then E . Those not IOTN trained should complete parts C or D then E

Part A IOTN referral Enter IOTN dental health component (DHC) of patient 1 to 5 plus the qualifier a to x or in part E the clinical reason for the referral. If DHC is 3 or less go to part B or D. (see overleaf or the referral pack) / DHC ?12345 / qualifier ?abcdefgh ilmpstx
Part B IOTN 3.6 referral. To qualify for treatment at the minimum IOTN level the patient must have a DHC of 3 plus an aesthetic component (AC) of at least 6 with the correct qualifier. The AC is highly subjective, so only IOTN certified clinicians should use this. Otherwise please use Parts C or D. (see overleaf or the referral pack) / Ac ?123456789101112 / qualifier ?abcdef
Part C Clinical referral. You must check one of the features below and give a reason for your referral in part E. A patient displaying one of the clinical occlusal traits in the list below should have a minimum IOTN (DHC) of at least 4 (see over leaf or in the referral pack).
1a Overjet >6mm but 1b if >10mm / 2a Reverse overjet > 1mm with speech defects or 2b > 3.5mm / 3. Traumatic overbite .
4 .Open bites>4mm / 5. Ant /post x bites with > 2mm displacement / 6 Crowded /malaligned teeth contact point displacement >4mm
7 Missing teeth / 8 Supernumeries / 9 Non palpable permanent canines aged >9 In one or more quadrants
10 impacted teeth inc. canines / 11 infra occluding deciduous teeth / 12. Possible surgical case / Features explained over page
Part D referral for advice. Please tick this box Then indicate in part E the nature of the advice required. Referral for advice is acceptable, however in such cases there must be a clinical reason which is clearly demonstrated below and not patient /parent request. To support your case you should include where possible any models radiographs and photographs taken. Please attach as much information as possible so that the orthodontist can assess the advice needed for treatment under the NHS regulations.
Part E please complete this part for all referrals.
Last caries incidence >12963 months ago. Current active caries NoYes If yes, explain below management plan indicating prognosis of teeth.
Confirm by checking the box that the patient does not have a digit sucking habit and their oral hygiene is satisfactory. All the necessary prevention and advice indicated in Delivering Better Oral Health has been provided and that continuing care will be offered. / Confirm by checking the box that copy of the consent form has been shared with the patient & parent /guardian and they are able to comply with the conditions.They should understand what is generally involved in orthodontic treatment and treatment is not guaranteed by this referral.
Relevant medical history
Clinical reasons from parts A B C or D, comments on caries, oral hygiene and any additional information
Orthodontic Specialist / I have read and understood the guidance notes for referral of this type
Referral Centre / Practitioner’s signature or Performer number
Date
Address 1
Address 2
. / Town / postcode
Please ensure all required sections are completed, attach a medical history form (child version) if necessary, relevant radiographs and any additional letter or information you may wish to include Electronic referral form O.R.F. e V 3.9.1 Designed by B. Hayes Aug 2015