For Referring Dentists Only

  • Patient Details

  • Details of referring practitioner

  • GP Practice

  • Details of Referral

  • Orthodontic referrals

    Referral to NHS secondary care

  • Severe skeletal anomalies and malocclusions likely to require interdisciplinary care such as orthognathic surgery, ankylosed teeth, impacted/ ectopic teeth*
  • Malocclusions requiring multidisciplinary care (advanced restorative care) such as hypodontia (more than 1 tooth missing in any quadrant), developmental anomalies affecting tooth structure, severe tooth surface loss*
  • Severely submerged deciduous teeth*
  • Patients with challenging physical or mental disabilities or complex medical history*
  • Cleft lip and/or palate or other craniofacial anomalies*
  • Patients over the age of 18 requiring complex multidisciplinary care*
  • Referral to NHS secondary care

  • Overjet of more than 6mm*
  • Reverse overjet with problems*
  • Traumatic overbite*
  • Open bites of more than 4mm*
  • Cross bite with displacement*
  • Missing teeth*
  • Supernumerary teeth*
  • Impacted teeth including canines*
  • Submerged deciduous teeth*
  • Severe crowding of teeth (contact point displacement of more than 4mm)*
  • 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:*
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