Download Orthodontics referral form - Hampshire Hospitals NHS Foundation

PCT REFERRAL PANEL – ORTHODONTIC CARE
(Over 18’s and Appeals Only)
Please complete this form for referral to the appropriate PCT Referral Panel for consideration if, as a clinician you believe
that the case of an individual patient is so singular as to justify an exception to the acceptance criteria for NHS
orthodontic care. All requests should be provided by the patients General Dental Practitioner, in writing and supported
by a clear description of the exceptional circumstances, copies of any relevant correspondence and other supporting
documentation, e.g. robost evidence of clinical effectiveness, consultant and other specialist assessments etc.
Please note: you must complete all sections of this form. If all sections are not completed, the form will be returned to
you and will not be referred for action as appropriate.
SECTION ONE
Why is it not appropriate for this patient to be referred via the standard route?
.
SECTION TWO – PATIENT DETAILS
Patient Name:
Address:
SECTION THREE – DETAILS OF REFERRER
Referrer:
Date:
Post Code:
Address:
DOB:
GP Practice:
SECTION FOUR – REFERRAL HISTORY
Please provide below, details of the patients health history relevant to this referral:
SECTION FIVE – INDEX OF TREATMENT NEED
Please provide details of the patients IOTN and other relevant measures (if appropriate):
SECTION SIX – PREVIOUS REFERRALS
Has the patient been referred previously to this panel? (please tick)
OFFICE USE ONLY:

YES
NO
CONTINUATION SHEET – PAGE 2 OF 2
PATIENT NAME:
DATE OF BIRTH:
SECTION SIX – REASON FOR REFERRAL
Please provide below any additional information to support the referral in response to the following:
1. Please give details of why this treatment is necessary:
2. What health gain / benefits will this intervention provide?
3. What is the likely outcome if this treatment is not funded?
SECTION SEVEN – OTHER COMMENTS
Please detail any other comments relevant to this referral below:
(Are there any special circumstances the PCT need to consider?)
SECTION EIGHT – ADDITIONAL DOCUMENTATION
Please detail below any additional documentation included to support this referral:
Please include a copy of the completed NHS orthodontic referral form
PLEASE SEND COMPLETED FORMS TO:
Orthodontic Central Referral Centre, Fanshawe Wing,Level B Royal South Hants Hospital
Brintons Terrace, Southampton, Hampshire, SO14 0YG
or FAX to: 023 8063 8141. Any queries please telephone: 023 8071 6695