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
    • *By clicking 'Submit' you are consenting to us replying, and storing your details. (see our privacy policy).