Download Referral for NHS Orthodontic Treatment

ReferralforNHSOrthodonticTreatment Pleasenotethatyoumustcompleteallsectionsofthisform.Ifanysectionisincomplete,your
referralmaynotbeaccepted.
SECTION1–PATIENTDETAILS
Name:
____________________________ Address:
____________________________ ____________________________ ____________________________
Postcode:
____________________________
DateofBirth:_________________
Gender:
Male
Female
Tel:____________________________
SECTION2–REFERRERDETAILS
Name:
____________________________ Signature:
____________________________
Date:
____________________________
PracticeStamp(Address/Tel)
SECTION3–REASONFORREFERRAL
Presentingmalocclusion:___________________________________________________________
Thepatienthasthefollowing:(Pleasetickallthatapply)
Hypodontia
ReverseOJ1mm+
Likelysurgicalcase
Anterioropenbite4mm+
Impactedteeth Crossbitewith2mm+displacement
Traumaticoverbite
Overjet>6mm
Malalignedcontactarea4mm+ Pleaseprovideanyadditionalinformationyoufeelweshouldknowbelow:
E.g.Doubtfulprognosisof6’s_______________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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ReferralforNHSOrthodonticTreatment
SECTION4–ADDITIONALINFORMATION
Patient’smedicalhistory:__________________________________________________________
Iconfirmthattheoralhygieneissatisfactoryandtheoralhealthisstabilised.
SECTION5–ENCLOSURES
IencloseanOPGtakenon___________
NoOPGhasbeentaken.
Oncecompleted,pleasereturnthisformtoeitherStgh-tr.referrals@nhs.netorCentralBooking
Service,StGeorge’sUniversityHospitalsNHSFoundationTrust,BlackshawRoad,Tooting,London,
SW170QT.
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