Colchester Smiles NHS dental referral form

Dentist NHS Referral

All NHS referrals must be submitted on the Essex NHS Orthodontic referral pro-forma. Please ensure the form is completed in full, so that each case can be accurately assessed for its level of urgency. All referrals are triaged and appointments are issued accordingly. If you’re unsure about any part of the referral, please don’t hesitate to contact our team for guidance.
Patient Information
Patient First Name
Patient Surname
Date of Birth
Gender
Address
Telephone
Please enter a valid phone number.Format: 0000 000 0000.
Mobile
Please enter a valid phone number.Format: 0000 000 0000.
Email
example@example.com
Date of Referral
Reason(s) for Referral
IOTN (DHC)
Impacted/Ectopic teeth (Indicate)

Supporting radiograph must be attached
Upper Teeth
Lower Teeth
Overjet (Measured in mm)
Overbite
Crowding
Spacing
Missing teeth developmentally (indicate)

Supporting radiograph must be attached
Upper Teeth
Lower Teeth
Cross Bites
Radiographs attached: OPG/PERIAPICAL/OTHER
Clinical/Additional Information
Medical conditions (including special needs)
Other information
Dental Practitioner Details
Name of Dental Practitioner

First NameLast Name
Email of Dental Practitioner (NHS.net secure practice email)
example@nhs.net
GDC Number
Practice Address

Street Address

Street Address Line 2
TownCityPost Code
Radiographs or other attachments

For any photos, xrays or additional information you wish to submit alongside this referral, please upload here.Accepted file types: jpg, gif, png, pdf.
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Dentist NHS Referral

Patient Information

Impacted/Ectopic teeth (Indicate)

Missing teeth developmentally (indicate)

Clinical/Additional Information

Dental Practitioner Details