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*

MaleFemale

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

NHSPrivate

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 5 (Overjet of over 9mm/ Missing teeth at least one tooth per quadrant/ Impaction of tooth due to crowding, displacement or pathology/ Reverse Overjet of 3.5mm With Speech and masticatory problem/ Submerged deciduous tooth/ Cleft lip & palate)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 toothIOTN 3 AND Aesthetic Component of 6 or above (Overjet of 3.5-6mm with incompetent lips/ Reverse overjet of 1-3.5mm/ Displacement of tooth between2-4mm/ Open bite between 2-4mm/ Overbite is increased, complete Without trauma/ Crossbite anterior or posterior leading to a displacement of between 1-2mm

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 18 months. Patient must be under 18 years 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