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Patient details Referrer details Name: Dentist name: ……………………………………………………………… DOB: …………………………………………………………………… ___/___/___ NHS / Private (Please tick) Practice name: ……………………………………………………………… Address: …………………………………………………………………… Practice address: …………………………………………………………… …………………………………………………………………… ..………………………………………………………… Postcode: …………………………… Tel: ………………………………………… CHI / HS No: …………………………… Email address: ………………………………………… Tel home: ……………………… Tel mobile: ……………………… Relevant Medical History: General assessment of dental health: Details: Oral hygiene: poor / fair / good Teeth of poor prognosis?: Dental History: Attendance: regular / infrequent / new to practice Other relevant details: Reason for referral Patient’s complaint: Radiographs enclosed: yes / no / emailed Other relevant details: Status of referral: routine / urgent (Please tick) Date of x-rays: ___/___/___ If urgent referral please clarify reason: (including details of overjet / canines if appropriate) Patient / Parent / Guardian understands why this orthodontic referral has been made and gives their consent to referral for orthodontic treatment. (Please tick) Referrer’s signature: [email protected] Date: ___/___/___ 14 Finaghy Rd South, Belfast BT10 0DR