Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Referral for NHS Orthodontic Treatment
Transcript
ReferralforNHSOrthodonticTreatment Pleasenotethatyoumustcompleteallsectionsofthisform.Ifanysectionisincomplete,your referralmaynotbeaccepted. SECTION1–PATIENTDETAILS Name: ____________________________ Address: ____________________________ ____________________________ ____________________________ Postcode: ____________________________ DateofBirth:_________________ Gender: Male Female Tel:____________________________ SECTION2–REFERRERDETAILS Name: ____________________________ Signature: ____________________________ Date: ____________________________ PracticeStamp(Address/Tel) SECTION3–REASONFORREFERRAL Presentingmalocclusion:___________________________________________________________ Thepatienthasthefollowing:(Pleasetickallthatapply) Hypodontia ReverseOJ1mm+ Likelysurgicalcase Anterioropenbite4mm+ Impactedteeth Crossbitewith2mm+displacement Traumaticoverbite Overjet>6mm Malalignedcontactarea4mm+ Pleaseprovideanyadditionalinformationyoufeelweshouldknowbelow: E.g.Doubtfulprognosisof6’s_______________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Page 1 of 2 ReferralforNHSOrthodonticTreatment SECTION4–ADDITIONALINFORMATION Patient’smedicalhistory:__________________________________________________________ Iconfirmthattheoralhygieneissatisfactoryandtheoralhealthisstabilised. SECTION5–ENCLOSURES IencloseanOPGtakenon___________ NoOPGhasbeentaken. Oncecompleted,pleasereturnthisformtoeitherStgh-tr.referrals@nhs.netorCentralBooking Service,StGeorge’sUniversityHospitalsNHSFoundationTrust,BlackshawRoad,Tooting,London, SW170QT. Page 2 of 2
