Orthodontic Referral Form
Standard online referral form for Feelgood Orthodontics. Complete the referrer, patient, dental/medical, safeguarding, referral, suitability, IOTN, and declaration sections.
Referrer details
Name of Referrer
*
First Name
Last Name
Job title
*
Organisation
*
Referrer/Organisation Address
*
Referrer/Organisation Postcode
*
Referrer/Organisation Phone
*
Please enter a valid phone number.
Format: 0000 000 0000.
Secure Email
*
example@example.com
Date of Referral
*
-
Month
-
Day
Year
Date
Patient details
Patient Surname
*
Patient First Name(s)
*
Patient Gender
*
Please Select
Male
Female
Prefer not to say
Patient Date of Birth
*
-
Month
-
Day
Year
Date
NHS Number
Patient Home Address
*
Patient Post Code
*
Patient/Parent Phone
Please enter a valid phone number.
Format: 0000 000 0000.
Patient/Parent Email
example@example.com
Dental and medical contacts
General Dentist Name
*
General Dentist Address
*
General Dentist Post Code
*
General Dentist Phone
*
Please enter a valid phone number.
Format: 0000 000 0000.
General Medical Practitioner Name
*
General Medical Practitioner Address
*
General Medical Practitioner Post Code
*
General Medical Practitioner Phone
*
Please enter a valid phone number.
Format: 0000 000 0000.
Safeguarding & support
Is this a Child Looked After?
*
Please Select
Yes
No
Are there any safeguarding concerns for this patient?
*
Please Select
Yes
No
Safeguarding concerns details
Interpreter required?
*
Please Select
Yes
No
Interpreter language
Special educational needs
Medical history and medication
Is patient under hospital care for a medical reason?
*
Please Select
Yes
No
If yes, which hospital
Referral specifics
Reason for Referral
*
Opinion
Treatment if appropriate
In active treatment
Orthognathic
Poor prognosis 6s
Summary of Problem
*
Priority
*
Please Select
Routine
Urgent
If Urgent, provide reason
Images enclosed
OPG
Lat Ceph
Periapical
Occlusal
Bitewings
Study models
Photographs
CBCT
Other image type
Motivation and suitability
Is the patient motivated to undergo orthodontic treatment (wear an appliance)?
*
Please Select
Yes
No
Is the patient dentally fit at the time of referral?
*
Please Select
Yes
No
Is oral hygiene good to excellent?
*
Please Select
Yes
No
Has the patient or parent been advised that they may not be eligible for NHS treatment?
*
Please Select
Yes
No
Has the patient been referred for or received orthodontic treatment on the NHS before?
*
Please Select
Yes
No
If yes, give details
IOTN - Missing teeth / Hypodontia
IOTN classification - Missing teeth / Hypodontia
*
More than one tooth absent per quadrant (not 8s) (PA/OPG required) - 5h
ONLY one tooth absent per quadrant (not 8s) (PA/OPG required) - 4h
Upload supporting radiograph(s) (PA/OPG)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
IOTN - Impacted tooth
IOTN classification
*
Unerupted maxillary central incisor (PA required) 5i
Impacted canine 5i
Impeded eruption of any other tooth 5i
Upload PA radiograph
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Notes
IOTN - Overjet (Increased)
IOTN classification for increased overjet
*
Overjet >9mm (5a)
Overjet >6mm (4a)
Overjet >3.5mm with incompetent lips (3a)
Selection guidance
Clinical notes
IOTN - Overjet (Reverse)
Reverse overjet >3.5 mm with masticatory difficulties (5m/4b)
Yes
Reverse overjet >1 mm with masticatory and speech difficulties (4m)
Yes
Reverse overjet >1 mm without masticatory and speech difficulties (3b)
Yes
IOTN - Crossbite (Anterior/Posterior)
>2 mm discrepancy between RCP and ICP (4c)
Yes
>1 mm discrepancy between RCP and ICP (3c)
Yes
Posterior lingual crossbite with no functional occlusal contact on one or both sides (4l)
Yes
IOTN - Displacement of contact points / Crowding
Contact point displacement
>4 mm (4d)
>2 mm (3d)
Notes on crowding / displacement
IOTN - Open bite
IOTN classification
*
Lateral or anterior open bite >4 mm (4e)
Lateral or anterior open bite >2 mm (3e)
Clinical notes
IOTN - Overbite
IOTN Overbite classification
*
Increased with gingival or palatal trauma (4f)
Increased with gingival or palatal contact but no trauma (3f)
Additional notes on overbite
IOTN - Additional features
Defects of cleft lip and palate and other craniofacial anomalies (5p)
Selected
Submerged deciduous teeth (5s)
Selected
Supernumerary teeth (4x)
Selected
Partially erupted teeth, tipped and impacted against adjacent teeth (4t)
Selected
Declarations
Declaration – I confirm that I have discussed the details of this referral with the patient and/or parent/carer
*
I confirm
Declaration – I agree to provide the patient and/or parent/carer with a copy of this referral
*
I agree
Submit Referral
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