For Referring Dentists Only

  • Patient Details

  • Details of referring practitioner

  • GP Practice

  • Details of Referral

  • Referral for other reasons

  • Patients who are over 18 for private assessment*
  • Patients who are under 18 for private assessment*
  • Advice concerning teeth of poor prognosis*
  • Second opinion required*
  • 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*
  • Please note that referrals to this service will be monitored for audit purposes To be completed by the clinician accepting the referral

  • This referral is appropriate for specialist primary/ secondary orthodontic care State reason:*
  • I’d like to be informed of exclusive offers and other practice informationyes
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