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Referrals
: NHS
This is the NHS referral form.
GDP details
GDP name*:
Practice name*:
Practice email*:
Practice address*:
Postcode:
Patient details
Patient name*:
Patients D.O.B*:
Patients NHS no:
Patient address*:
Telephone*:
Mobile:
Reason for referral
Significant orthodontic abnormality
Significant patient or parental concern
Extraction advice required
Already wearing appliances
Teeth with poor prognosis
Second opinion - please give detail below
Other - please give detail below
Further detail:
Reason for early referral (patient is 10 or under)
Incisor in crossbite with mandibular displacement
Missing teeth (hypodontia)
Overjet > 8mm
Upper canine tooth which cannot be palpated at ten years
Extra teeth (supernumerary)
Other - please give detail
Further detail:
Radiographs
File 1
File 2
Smile photograph
File 3
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