For Referring Dentists Only

      • Patient Details

      • Details of referring practitioner

      • Details of Referral

      • Responsibilities of referring dentist

    • I have discussed the commitment required to undertake orthodontic treatment with the patient and the patient is highly motivated and is prepared to wear appliances*

    • The patient has good oral hygiene and no active disease*

    • I have provided preventive advice and treatment where necessary for the patient and will continue to do so through orthodontic treatment*

    • I will work with the orthodontist to enable treatment to be progressed including the extraction of teeth where necessary and preventive/ restorative work as required*

    • I have enclosed relevant radiographs and study models where appropriate*

    • This referral is appropriate for specialist primary/ secondary orthodontic care State reason:*