Download Orthodontic Referral Form (DOC)

Building our community . . . one child at a time
Children’s Fund: Oral Health Application (Orthodontics)
Program Information
The Oral Health Program has two components: orthodontics and dental treatment. Families may
self-refer or they can be referred by health care professionals and community agencies.
For our orthodontic component, Burns Memorial Fund (BMF) is able to assist 6-10 children per year, who
have severely handicapping orthodontic issues, with the cost of their orthodontic treatment. BMF
generally runs one orthodontic screening per year in the spring. This, however, depends on a number of
factors, including availability of funds.
In order to be placed on the list to attend an orthodontic screening, families must have their dentist or
orthodontist complete our pre-screening referral form (see below) and have it forwarded to our office.
Please note that applicants will be responsible for any cost incurred in having this form completed.
If it appears that the child meets the initial requirements for a screening, families will be notified by mail a
few weeks prior to the scheduled date. The letter will provide specific details about the screening and how
to confirm your attendance. Screenings are free of charge.
After the screening, families of the children most in need of orthodontic treatment will be asked to show
financial need. As funds are limited, only the most severe cases are considered for financial assistance.
Note: Children must be under 20 years of age or younger, must not have begun any orthodontic
treatment, and must live in the City of Calgary (for at least the past 6 months) before applying to our Oral
Health Program. Families must also meet low income guidelines.
Should you have any questions regarding the Oral Health Program or this referral form, please contact
Portia, Communications and Grants Coordinator, via the information below.
Completed applications can be submitted via fax, mail, or email to:
Burns Memorial Fund
Kahanoff Centre
1120, 105 12th Avenue SE
Calgary, AB T2G 1A1
Phone: (403) 234-9396 | Fax: (403) 233-0513
[email protected] | www.burnsfund.com
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BURNS MEMORIAL FUND ORTHODONTIC ASSESSMENT* REFERRAL FORM
*(BASED ON THE IOTN ASSESSMENT SYSTEM)
THIS FORM IS TO BE COMPLETED BY THE REFERRING DENTIST OR ORTHODONTIST
CHILD'S FIRST NAME & SURNAME
DATE OF BIRTH
GENDER
PARENT/LEGAL GUARDIAN’S FIRST NAME & SURNAME
MAIN PHONE #
EMAIL ADDRESS
ADDRESS (HOUSE/APT. NUMBER, STREET, CITY/PROVINCE, POSTAL CODE)
REFERRING DOCTOR
PHONE #
DATE
ADDRESS
PATIENT HAS BEEN UNDER MY CARE SINCE:
________________________________________
ALTHOUGH EARLY TREATMENT IS BENEFICIAL IN MANY CASES, FOR BUDGETARY REASONS BURNS MEMORIAL FUND IS
ABLE TO PROVIDE FUNDING ONLY FOR CASES INVOLVING PERMANENT DENTITION.
OCCLUSAL ANALYSIS – PLEASE “X” APPROPRIATELY
GRADE 5 (VERY GREAT)
5.1
5.2
5.3
5.4
5.5
Defects of Cleft Lip and Palate
Increased overjet > 9 mm
Reverse overjet > 3.5 mm with reported masticatory and speech difficulties
Impeded eruption of teeth (except third molars) due to crowding, displacement, the presence of supernumerary teeth,
retained primary teeth, or any pathological cause
Extensive hypodontia with restorative implications (more than one tooth missing in one quadrant) requiring prerestorative
orthodontics
GRADE 4 (GREAT)
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
Increased overjet > 6 mm but </= 9 mm
Reverse overjet > 3.5 mm with no masticatory or speech difficulties
Reverse overjet > 1 mm but < 3.5 mm with masticatory and speech difficulties
Anterior or posterior crossbites with > 2 mm discrepancy between retruded contact position and intercuspal position
Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments
Severe displacement of teeth > 4 mm
Extreme lateral or anterior openbites > 4 mm
Increased and complete overbite with gingival or palatal trauma
Less extensive hypodontia requiring prerestorative orthodontics or orthodontic space closure to obviate the need for
prosthetics
PLEASE CIRCLE
ORAL HYGIENE
GOOD
FAIR
POOR
UNABLE TO COMMENT
RESTORATIVE NEEDS
SLIGHT
MODERATE
HIGH
UNABLE TO COMMENT
PRESENT RESTORATIVE LEVELS
SLIGHT
MODERATE
HIGH
UNABLE TO COMMENT
DUE TO THE HIGH DEMAND AND LIMITED FUNDS WE PREFER TO SCREEN ONLY THOSE CHILDREN WHO ARE IN THE
HIGHEST RANGE OF ORTHODONTIC NEED. IF YOU FEEL THAT SPECIAL CIRCUMSTANCES WARRANT AN EVALUATION
FOR A LESSER MALOCCLUSION, PLEASE INCLUDE THOSE FACTORS.
COMMENTS:
SIGNATURE OF THE REFERRING DENTIST/ORTHODONTIST:
Burns Memorial Fund wishes to thank the participating community orthodontists for their generous support in providing a much needed
service to families needing assistance. Their important involvement allows us to bring more smiles to children’s faces. Please return the
completed referral form to:
Burns Memorial Fund
1120, 105 12th Avenue SE
Calgary, AB T2G 1A1
Phone: (403) 234-9396 | Fax: (403) 233-0513 | Email: [email protected] | www.burnsfund.com
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