Download Enclosure 3 - Referral for NHS Orthodontic

Enclosure 3 – V5
A Collaboration between NHS Hampshire & Solent NHS Trust
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.
3. Please complete all sections of this referral form.
4. 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 patient’s treatment will be delayed.
Please see accompanying notes for further details.
SECTION ONE – PATIENT DETAILS
Patient Name
Date of Birth
Address and
Postcode
Contact Tel(s):
GP Practice Name and
Address
SECTION TWO – DETAILS OF REFERRER
Name of Referrer
Practice Stamp (Address and Contact Tel):
Signature
Date
Yes
or
In-house referral
SECTION THREE – REFERRAL HISTORY
No
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
(Explanation required)
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
5a
Increased overjet greater than 9mm
5i
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
5m
5h
5p
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
5s
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
4a
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
4c
Anterior or posterior crossbites with greater than 2mm discrepancy between retruded
contact position and intercuspal position
4d
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
4h
Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic
space closure to obviate the need for a prosthesis
Posterior lingual crossbite with no functional occlusal contact in one or both buccal
segments.
Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory
and speech difficulties
Partially erupted teeth, tipped and impacted against adjacent teeth
4l
4m
4t
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).
Scan (1-10)
Increased overjet greater than 3.5mm but less or equal to 6mm with incompetent lips
3b
Reverse overjet greater than 1mm but less than or equal to 3.5mm
3c
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
3f
Deep overbite complete on gingival or palatal tissues but no trauma
Other Reason for Referral – IOTN N/A
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 Referral Centre, Solent NHS Trust Dental Single Point
of Access, Level A, Royal South Hants Hospital, Brintons Terrace, Southampton, SO14 0YG or
Fax To: 023 80713279
Any queries please telephone: 023 8071 6695
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