Wiltshire NHS Orthodontic Referral Form
Practice
*
Practitioners Name
*
Address
Address 1
Postcode
Email
*
example@example.com
Referral Date
/
Day
/
Month
Year
Back
Next
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
Mobile number
NHS Number
Back
Next
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
Select if radiographs to be enclosed
Radiographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Radiographs
More?
Radiographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Radiographs
More?
Radiographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Radiographs
More?
Radiographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Radiographs
More?
Radiographs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
Back
Next
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
Back
Next
Comments
Signature
Preview PDF
Submit
Should be Empty: