Orthodontic Referral Cardiff | Orthodontist Cardiff

Only Referrals made on this form will be accepted for NHS Orthodontic treatment in South East Wales

Referring Practitioner:

Name:

Email:

Telehone:

Practice:

Date of referral:

Performer Number:

Patient Details:

Name:

D.O.B:

Telehone:

Address:

SECTION 1 - BASIC INFORMATIONIf you are referring for treatment you will need to provide all the details below and complete SECTION 2.

Is the patient motivated to undergo orthodontic treatment (wear appliance) ?

Yes

Is the patient dentally fit at the time of referral ?

Yes

Is oral hygiene 'good' to 'excellent' ?

Yes

Have the patient and parents been advised that they may not be eligable for NHS treatment ?

Yes

Please do not refer for orthodontic 'treatment' ot 'treatment planning' if you cannot tick 'Yes' against all of the above.

Is the patient in / very nearly in permanent dentition ?

Yes

If patient is in primary dentition or early mixed dentition, please state reason for early referral:

Referral For: (Please select one from the choices below and ensure all radiographs are attached)

Advice only (complete sections 3 & 4)

Assessment & treatment plan (complete sections 3 & 4)

Assessment & treatment (complete sections 2 & 4)

Please use the below to attach any relevant files:

SECTION 2 - THIS SECTION MUST BE COMPLETED IF YOUR REFERRAL IS FOR TREATMENT

Features in BOLD and UPPERCASE should be referred to a consultant in orthodontics in your local hospital. Cases in bold may be accepted by specialist practice or by the orthodontic department at your local hospital. Referrers are advised to liaise with their orthodontic providers before referring such cases.

Overjet

6.1mm - 9mm

Greater than 9mm

Reverse overjet greater than 1mm

Overbite

Deep or potentially traumatic

Extreme open bites lateral or anterior (greater than 4mm)

Crowding / Spacing

Moderate crowding (2mm or more contact point displacement)

Severe spacing (4mm or more contact point displacement)

Severe crowding (4mm or more contact point displacement)

Hypodontia

Up to one tooth missing in any quadrant

MORE THAN ONE TOOTH MISSING IN ANY QUADRANT

Other Clinical Features

Ectopic/impacted teeth requiring surgery

Crossbites anterior or posterior with displacement greater than 4mm

SEVERE JAW DISCREPANCIES

CLEFT LIP/PALATE OR OTHER CRANIOFACIAL CONCERN

IOTN (If known)

IOTN 5

IOTN 4

IOTN 3 with AC 6 or above

SECTION 3 - ADVICE AND / OR TREATMENT PLANNING

If the patient is being referred for advice and/or treatment planning, it is assumed that you will be providing the required NHS treatment to the patient. Please indicate the nature of the advice required and/or your provisional treatment plan (to be confirmed by the specialist/consultant) e.g. URA to correct crossbite or space maintainer:

SECTION 4 - OTHER INFORMATION

Relevant Dental History (if urgent please specify):

Relevant Medical History and GP's name:

Relevant Social History:


	Orthodontic Referral / Cyfeired Orthodontig

	Please Click Here to download our orthodontics referral form, or complete the online form below.

	Only Referrals made on this form will be accepted for NHS Orthodontic treatment in South East Wales Referring Practitioner: Name: Email: Telehone: Practice: Date of referral: Performer Number: Patient Details: Name: D.O.B: Telehone: Address: SECTION 1 - BASIC INFORMATIONIf you are referring for treatment you will need to provide all the details below and complete SECTION 2. Is the patient motivated to undergo orthodontic treatment (wear appliance) ? Yes No Is the patient dentally fit at the time of referral ? Yes No Is oral hygiene 'good' to 'excellent' ? Yes No Have the patient and parents been advised that they may not be eligable for NHS treatment ? Yes No Please do not refer for orthodontic 'treatment' ot 'treatment planning' if you cannot tick 'Yes' against all of the above. Is the patient in / very nearly in permanent dentition ? Yes No If patient is in primary dentition or early mixed dentition, please state reason for early referral: Referral For: (Please select one from the choices below and ensure all radiographs are attached) Advice only (complete sections 3 & 4) Assessment & treatment plan (complete sections 3 & 4) Assessment & treatment (complete sections 2 & 4) Please use the below to attach any relevant files: SECTION 2 - THIS SECTION MUST BE COMPLETED IF YOUR REFERRAL IS FOR TREATMENT Features in BOLD and UPPERCASE should be referred to a consultant in orthodontics in your local hospital. Cases in bold may be accepted by specialist practice or by the orthodontic department at your local hospital. Referrers are advised to liaise with their orthodontic providers before referring such cases. Overjet 6.1mm - 9mm Greater than 9mm Reverse overjet greater than 1mm Overbite Deep or potentially traumatic Extreme open bites lateral or anterior (greater than 4mm) Crowding / Spacing Moderate crowding (2mm or more contact point displacement) Severe spacing (4mm or more contact point displacement) Severe crowding (4mm or more contact point displacement) Hypodontia Up to one tooth missing in any quadrant MORE THAN ONE TOOTH MISSING IN ANY QUADRANT Other Clinical Features Ectopic/impacted teeth requiring surgery Crossbites anterior or posterior with displacement greater than 4mm SEVERE JAW DISCREPANCIES CLEFT LIP/PALATE OR OTHER CRANIOFACIAL CONCERN IOTN (If known) IOTN 5 IOTN 4 IOTN 3 with AC 6 or above SECTION 3 - ADVICE AND / OR TREATMENT PLANNING If the patient is being referred for advice and/or treatment planning, it is assumed that you will be providing the required NHS treatment to the patient. Please indicate the nature of the advice required and/or your provisional treatment plan (to be confirmed by the specialist/consultant) e.g. URA to correct crossbite or space maintainer: SECTION 4 - OTHER INFORMATION Relevant Dental History (if urgent please specify): Relevant Medical History and GP's name: Relevant Social History:

Orthodontic Referral / Cyfeired Orthodontig