Wiltshire NHS Orthodontic Referral Form
Practice
*
Practitioners Name
*
Address
Address 1
Postcode
Email
*
example@example.com
Referral Date
/
Day
/
Month
Year
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Patient Details
Please provide the following patient information
Patient Name
*
Patient Address
Date of Birth
/
Day
/
Month
Year
Patient Email
*
(This address will be used for all letters and appointment confirmations)
Telephone number
Format: (00000) 000000.
Mobile number
Format: 00000000000.
NHS Number
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Reason for referral
*
Significant Orthodontic abnormality
IOTN 3 or below
IOTN 4 or 5
Extraction advice required
Teeth with poor prognosis
Significant patient or parental concern
Already wearing appliances
Second opinion
Radiographs
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Radiographs
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Relevant Dental Information
(Tick all that apply)
Oral Hygiene
Good
Average
Poor
High Caries Experience
Fluoride supplements
Erosion
Patient / Parent warned that mild malocclusion may not be eligible for NHS funding
Yes
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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
5m- Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties
5h - Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics
5p - Defects of cleft lip or palate and other craniofacial anomalies
5s - Submerged deciduous teeth
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
4l - Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments.
4m - Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory and speech difficulties
4t - Partially erupted teeth, tipped and impacted against adjacent teeth
Grade 3 – Patient may not need to be seen. Referral to be assessed re eligibility for treatment – Bo rderline Need
3a - 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- Anterior or posterior crossbites with greater than 1mm but less than or equal to 2mm discrepancy between retruded contact position and intercuspal position
3d - 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
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