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Enclosure 3 – V4 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 x If Yes, please provide details (who and why) David Gale 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: Page 1 of 2 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 Other Reason for Referral (e.g. Caries of doubtful prognosis) PLEASE SEND COMPLETED FORMS TO: Orthodontic Central Referral Centre, Solent NHS Trust, Oakhill House, 2 – 6 Romsey Road, Shirley, Southampton, SO16 4BZ. OR FAX TO: 023 8077 2585. Any queries please telephone: 023 8071 6695. Page 2 of 2 Eligibility to be reviewed. Patient to be assessed within Primary Care. Patient may not be eligible for NHS treatment. 3a