Download Orthodontics referral form - Hampshire Hospitals NHS Foundation

A Collaboration between Portsmouth City,
Southampton City, Hampshire Primary Care Trust
(PCTs)
Enclosure 3
REFERRAL FOR NHS ORTHODONTIC ASSESSMENT
Please complete this form for any patient in need of NHS orthodontic treatment that meets the following criteria:
1. Patient to be less than 18 years of age at the point of referral (see guidance)
2. Patient must meet the requirements of the Index of Treatment Need (IOTN) 4, 5 and 3 with an aesthetic
component of 6 or above (SCAN) to be eligible for NHS treatment.
 Please complete all sections of this referral form.
 Please include a copy of an OPG (if available) – Please see Section Five
Please note that you must complete all sections of this form. If all sections are not completed, the form will be
returned to you and the patients treatment will be delayed.
Please see accompanying notes for further details.
SECTION ONE – PATIENT DETAILS
Patient Name
Date of Birth
Address
Contact Tel(s):
Post Code
GP Name and Address
SECTION TWO – DETAILS OF REFERRER
Name of Referrer
Practice Stamp (Address and Contact Tel):
Signature
Date
SECTION THREE – REFERRAL HISTORY
Has this patient been referred before for NHS orthodontic treatment?
YES
No
If Yes, please specify where
SECTION FOUR – CHOICE OF PROVIDER
Has this patient or referrer expressed a preference of Provider?
Yes
No
If Yes, please provide details (who and why)
Please note: If the patient or referrer does not express a preference, the patient will be allocated to an appropriate Provider with
capacity at that time. If the patient or referrer has expressed a preference this Provider may not be suitable and if the wait is above
18 weeks you may be contacted to discuss other alternatives.
SECTION FIVE – REASON FOR REFERRAL
Please provide below any additional information to support the referral
(please include the date of GDP appointment when possible need for orthodontic treatment identified)
Standard Referral
Second Opinion
Transfer of Care
OFFICE USE ONLY:
OPG Enclosed (please tick)
Dispute
REFERENCE NO:
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CONTINUATION SHEET – PAGE 2 OF 2
Patient Name
Date of Birth
CRITERIA - Please tick one box only. Start at the top and work down until you identify the component that
best fits the patient being referred:
Grade 5 – Patient in Need of Treatment
5i
5m
Impeded eruption of teeth (excluding third molars) due to crowding, displacement,
the presence of supernumerary teeth, retained deciduous teeth & any pathological
cause
Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties
5a
Increased overjet greater than 9mm
5h
5c
Extensive hypodontia with restorative implications (more than one tooth missing in
any quadrant) requiring pre-restorative orthodontics
Defects of cleft lip or palate and other craniofacial anomalies
5e
Submerged deciduous teeth
Patient to
be referred
to Primary
Care for
assessment
Patient to
be referred
to
Secondary
Care for
assessment
Grade 4 – Patient in Need of Treatment
4h
4a
Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic
space closure to obviate the need for a prosthesis
Increased overjet greater than 6mm but less than or equal to 9mm
4b
Reverse overjet greater than 3.5mm with no masticatory or speech difficulties
4m
4d
Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory
and speech difficulties
Anterior or posterior crossbites with greater than 2mm discrepancy between retruded
contact position and intercuspal position
Posterior lingual crossbite with no functional occlusal contact in one or both buccal
segments.
Severe contact point displacements greater than 4mm
4e
Extreme lateral or anterior open bites greater than 4mm
4f
Increased and complete overbite with gingival or palatal trauma
4t
Partially erupted teeth, tipped and impacted against adjacent teeth
4x
Presence of supernumerary teeth
4c
4l
Patient
likely to be
seen in
Primary
Care
Grade 3 – Patient may not need to be seen. Referral to be
assessed re eligibility for treatment – Borderline Need
Please tick box for Dental Health Component & score between 1-10 for the Aesthetic Component (SCAN).
Increased overjet greater than 3.5mm but less or equal to 6mm with incompetent lips
scan
3b
Reverse overjet greater than 1mm but less than or equal to 3.5mm
scan
3c
scan
3d
Anterior or posterior crossbites with greater than 1mm but less than or equal to 2mm
discrepancy between retruded contact position and intercuspal position
Contact point displacements greater than 2mm but less than or equal to 4mm
3e
Lateral or anterior open bite greater than 2mm but less than or equal to 4mm
scan
3f
Deep overbite complete on gingival or palatal tissues but no trauma
scan
Other Reason for Referral – IOTN N/A
scan
Eligibility to be reviewed. Patient to be
assessed within Primary Care. Patient
may not be eligible for NHS treatment.
3a
Other Reason for Referral (e.g. Caries of doubtful prognosis)
PLEASE SEND COMPLETED FORMS TO: Orthodontic Central Referral Centre, Fanshawe Wing, Level
B, Royal South Hants Hospital, Brintons Terrace, Southampton, SO14 0YG OR FAX TO: 023 8063 8141.
Any queries please telephone: 023 8071 6695
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