New Patient Registration Form

48 Woodberry Grove, London N4 1SN www.manorortho.co.uk

Tel: 0208 800 8581 Fax: 0208 802 2403

Email: Manor.clinic@nhs.net

Patient's Details

Patient's Name

First NameLast Name

Patient's Address:

Street Address

City

Post Code

Gender

Date of Birth

Date

Patient's Tel

Patient's Mobile

SMS will be sent for confirmation

Relevant Medical and Dental History

Please specify reason for (self) referral

Is this an NHS or Private Referral

If an NHS Referral, please confirm that the Dental Health Component of the Index Of Orthodontic Need (IOTN) is 4 or 5. If the score is 3, the patient may qualify if the Aesthetic Component of the IOTN is 6 or above (please search on internet for images of Aesthetic Component of IOTN and score accordingly). IOTN's Dental Health Component Scores 1 or 2 for the Dental Component can only be treated on private basis

IOTN 4 (Overjet between 6-9mm/ Overbite is increased, complete AND traumatic/ Reversed Overjet greater than 3.5mm/ Crossbite greater than 2mm/ Displacement of tooth greater than 4mm to neighbouring tooth/ Open bite greater than 4mm/ Missing tooth or teeth/ Crossbite lingual or posterior with no functional occlusion/ Reverse Overjet between1-3.5mm WITH speech or masticatory problems/ Partially Impacted or tipped tooth/ Extra tooth

Referring Dentist's Details

If you are a dentist referring a patient for NHS orthodontic treatment, please inform patient current waiting time for assessment is about TWO YEARS. Patient must be under 18 year old

Dentist's Name

First NameLast Name

Practice Name

Practice Tel

Practice Address:

Street Address

City

Post Code

Dr's Email Address

Please email digital radiographs, photographs or scanned documents separately to manor.clinic@nhs.net stating patient's name and date of birth