Download NHS Patient Referral Form

Please see reverse of form for guidance notes and where to send your referral.
ORTHODONTIC REFERRAL FORM for patients with IOTN 3.6 or above who have never started a course of treatment, except when < 10 years old
Patients Details
NHS number
Name
Date of birth
Address
Tel
Sex M F
Age
Mobile
Town
postcode
Email
Referring Practitioner Details
Name
Tel
Practice name
Mobile
Address
NHS Email
Town
Exam date
postcode
Clinicians who are trained in IOTN may complete parts A,B or D then E . Those not IOTN trained should complete parts C or D then E
Part A IOTN referral. Enter IOTN dental health component (DHC) of patient 1 to 5 plus the qualifier a to x or in
part E the clinical reason for the referral. If DHC is 3 or less go to part B or D
(see over leaf or the referral pack)
DHC
Part B IOTN 3.6 referral. To qualify for treatment at the minimum IOTN level the patient must have a DHC of 3
qualifier
c
qualifier
plus an aesthetic component (AC) of at least 6 with the correct qualifier. The AC is highly subjective, so only IOTN A
certified clinicians should use this. Otherwise please use Parts C or D
(see overleaf or the referral pack)
Part C Clinical referral. You must check one of the features below and give a reason for your referral in part E. A patient displaying one
of the clinical occlusal traits listed below should have a minimum IOTN (DHC) of at least 4.
( see overleaf or in the referral pack )
1a Overjet >6mm
4 .Open bites>4mm
but 1b if >10mm
2a Reverse overjet > 1mm with functional defects
5. Ant /post x bites with > 2mm displacement
7 Missing teeth
8 Supplemental teeth
10 impacted teeth inc. canines
or 2b > 3.5mm
3. Traumatic overbite
.
6 Crowded /malaligned teeth contact point displacement >4mm
9 Non palpable permanent canines aged >9 In one or more quadrants
11 infra occluding deciduous teeth
12. Possible surgical case
Features explained over page
Part D referral for advice. Please tick this box
Then indicate in part E the nature of the advice required. Referral for advice is
acceptable, however in such cases there must be a clinical reason which is clearly demonstrated below and not patient /parent request.
To support your case you should include where possible any models radiographs and photographs taken. Please attach as much
information as possible so that the orthodontist can assess the advice needed for treatment under the NHS regulations.
Part E please complete this part for all referrals
Last caries incident
months ago. Current active caries no / yes If yes, explain below management plan indicating prognosis of teeth.
Confirm by checking the box that the patient does not have
.Confirm by checking the box that copy of the consent form has been
a digit sucking habit and their oral hygiene is satisfactory. All the shared with the patient & parent /guardian and they are able to comply
necessary prevention and advice indicated in Delivering Better with the conditions. They should understand what is generally involved
Oral Health has been provided and that continuing care will be in orthodontic treatment and treatment is not guaranteed by this
offered.
referral
Relevant medical
history
Clinical reasons from parts A B C or D, comments on caries, oral hygiene and any additional information
Specialist
I have read and understood the guidance notes for referral of this type
Centre
Practitioner’s signature
Address
Town
postcode
Date
Please ensure all required sections are complete, attach a medical history form (child version) if necessary, relevant radiographs and any
additional letter or information you may wish to include.
Paper only referral form
O.R.F.p V 2.9 Designed by B. Hayes Aug 2015.
Please note this orthodontic referral form is limited to patients who have never had a
previous course of NHS treatment, except when under the age of 10. You must obtain
prior approval from NHS England before referring patients currently in treatment or
those who have already received orthodontic treatment under the NHS
Where to refer: A referral must be made in accordance with the Strategic Framework for Orthodontics (2015). An assessment of the
complexity of the case made and referred to a provider of the appropriate skill level and facilities for the procedure. Please use the
chart below to determine the most suitable orthodontic provider. You will need to give the patient a choice of all orthodontic providers
including their waiting times in order that the patient /parent can chose a provider within the appropriate level
Complexity
Level 2 Primary care specialist
practice or general practice
Level 3a Primary care specialist
practice
Procedure
Straight forward interceptive measures;
removable appliances, non-complex fixed
appliance alignment for patients without
skeletal discrepancies or significant
anchorage demands.
Provider
Orthodontist on specialist list or GDP with
additional orthodontic skills
Routine orthodontic treatment of skeletal
discrepancies with removable functional and
fixed appliances. Restorative and surgical
problems including impacted teeth where an
interdisciplinary liaison approach can be
managed in specialist practice
Orthodontist on specialist list
Level 3b Hospital consultant service
Patients in the developing
Patients
severe skeletal disproportion or
Patients inwith
the developing
craniofacial syndromes, complex restorative or
surgical procedures requiring a multi-disciplinary
approach. Patient with medical developmental,
social or psychological concerns not suitable for
specialist practice.
Consultant orthodontist or orthodontist on
specialist list
Where possible level 2 and 3a complexity should be delivered in primary care and training setting, 3b delivered primarily in a hospital.
A more detailed description of the complexity levels and provider descriptors can be found in the Strategic Framework for Orthodontics.
When to refer: The majority of orthodontic treatment can commence in the late mixed and early permanent dentition. If the child needs early
interceptive treatment use Part D stating the reasons. Patients referred too early for treatment will be sent back to the referring practitioner. They
should not be referred early in an attempt to circumvent long waiting lists, as this is unfair on other patients, already on a waiting list, who were
referred at the appropriate time. The referral pack contains further detailed guidance on patient referral.
Orthodontic treatment is time consuming, sometimes uncomfortable and requires commitment from the patient. Patients with a poor oral hygiene
should not be referred until they can demonstrate appropriate levels of plaque control. It is important that you discuss the nature of orthodontic
treatment with your patient before referring them and reinforce the commitment they have agreed to in the patient contract.
It is important that patients continue to visit their dentist for routine continuing care. Orthodontic patients should be considered at risk for caries and
practitioners should consider Delivering Better Oral Health when considering preventative advice and therapies. The use of a high fluoride toothpaste
may be indicated (2800ppm or for older children 5000ppm)
Parts A to D more detailed explanations.
Part A IOTN referral dental health component (DHC). This is the preferred section for referral for those clinicians familiar
with this index, as it indicates clearly the patient’s need for treatment. The DHC must be at least 3 with an aesthetic component
of 6 or above to qualify for treatment under the NHS. You must also add the qualifier a to x (used to identify deviant occlusal
traits) or the clinical reason in part E, so the nature of the problem is identified. You can use part C. if you are not trained in
IOTN. The referral pack has more detailed information on the IOTN.
Part
B IOTN
3.6ofreferral.
This section
applies
to patients in
with
DHC
of 3. and
Youearly
mustpermanent
include qualifier
a to If
x or
clinical
When to refer
:The
majority
orthodontic
treatment
can commence
thealate
mixed
dentition.
thethe
child
needs early
reason use
in part
ED
and
the aesthetic
component
comparing
the patient
12 referred
standardised
This practitioner.
interceptive treatment
Part
stating
the reasons.
Patients(AC)
are derived
referredfrom
too early
for treatment
theywith
will be
back pictures.
to the referring
bereferred
at least early
6 to create
the lowest
referral category
of 3.6 lists,
If no Performer
withinon
a other
practice
has undertaken
training
Patients shouldmust
not be
in an attempt
to circumvent
long waiting
as this is unfair
patients,
already onIOTN
a waiting
list, who were
(nb for newlytime.
qualified
UK graduates
this is part
of their
training)
and they
are notreferral.
confident to provide an IOTN score, using
referred at the appropriate
The referral
pack contains
further
detailed
guidance
on patient
the colour photographs provided, Part C or D can be completed instead.
Orthodontic treatment is time consuming, sometimes uncomfortable and requires commitment from the patient. Patients with poor oral hygiene should
C clinical
referral.appropriate
If you are uncertain
of the IOTN,
by Itidentifying
onethat
of the
features
listed
to 12 you treatment with
Fold
not
be-- referred Part
until they
can demonstrate
levels of plaque
control.
is important
youclinical
discuss
the nature
of1orthodontic
should
have awarded
the patient
a DHC
of give
at least
4. By adding
your patient before
referring
them. They
should with
be aware
and
commitment
that:your reasons for the referral in part D the orthodontist
can confirm a valid IOTN score to see the patient. You will need advice if you feel 3.6 is applicable as the AC is not scored.

It is important that all appointments are kept
1a 1b Overjet:
from the most prominent of the four incisors.

Appliances
must be measured
worn as indicated
2a 2b may
Reverse
consider
referral
to hospital.

Treatment
take overjet:
between In
18severe
and 30cases
months
and that
a period
of retention will be required (which is likely to be for the rest of their life)
3) Traumatic
Increased
complete
withtosigns of trauma to the labial or palatal tissues.

Dietary
advice and overbite:
oral hygiene
instructions
must overbite
be adhered
Openabites
Ant/Post:
must be greater
than 4treatment
mm.

They4)
require
genuine
interestthese
in undertaking
orthodontic
with fixed appliances
5) Ant/ Post X bite with displacement: mandibular displacement from RCP to ICP greater than 2mm.

They must achieve and maintain an excellent standard of oral hygiene and be dentally fit
6) Crowded / Misaligned Teeth: one or more teeth must have a contact point displacement >4mm premolar rotations do not

They are only entitled to receive 1 course of treatment from one practice; if their treatment is discontinued by either patient or practice, they
count.
would only receive a 2nd course of treatment in very exceptional circumstances which would be considered by the Regional IFR Panel. The
7) Missing teeth: this relates to: a) Hypodontia, congenitally absent teeth, commonly upper laterals or second premolars (third
exception to this would be moving a considerable distance where this was not planned at the point of referral
molars do not count) b) Avulsed teeth or inappropriate extractions (eg space remaining due to early loss of one or more first

Orthodontic
molars)patients will be required to sign a contract with the providing orthodontist. This is in the referral pack
8) Presence of supernumerary teeth: Extra teeth causing a problem.
It is important that
patients
continue
to visit canines.
their dentist
formaxillary
routine continuing
care. beOrthodontic
should
beby
considered
at risk for caries and
9) Non
palpable
permanent
If the
canines cannot
palpated inpatients
the buccal
sulcus
age 9-10 years,
practitioners should
consider
Delivering
Better investigations
Oral Health when
considering
advice and therapies. The use of a high fluoride toothpaste
they may
be ectopic
and further
should
be carriedpreventative
out.
may be indicated
for older
children
5000ppm)
10)(2800ppm
Impactedorteeth:
a) simple
tipped
teeth causing food packing b) moderate /severe impactions, including impeded eruption,
not enough room for a tooth to erupt. Including impacted and palatal canines.
11) Infra occluding (Submerged) deciduous teeth: these may prevent the eruption of the permanent teeth.
12) Possible surgical case: for severe skeletal discrepancy, defects of cleft lip palate, craniofacial anomaly.
Part D referral for advice. There are many times when orthodontic advice can aid your treatment plans for a patient,
these may include: early intervention, caries management and extractions, disorders of eruption retained or missing teeth. You
will need to supply a description of the orthodontic problem and include if possible radiographs, photos and study models. The
orthodontist can then decide if an assessment is necessary. If the patient qualifies for reasons in A, B or C then you could use
that route, with a note about the advice required. There will be instances where the patient /parent push for a referral but the
need does not meet the NHS criteria. Referral for advice under the NHS should not be made in those circumstances.