Referral Date: 16/12/2018







Referring Dentist:
Dentist Name: Practice Name: Address: Post Code:
Phone: Email Address:


Surname: First Name:

Date of Birth

Home phone no:
Work phone no:
Mobile no:
Email Address:

NHS Private NHS Discuss options with patient

We only accept children (under 18 years) as NHS patients. Adults (over 18 years) are seen as private patients.

Tick reason for referral (if no reason given this form will be returned)

Significant orthodontic abnormality
Extraction advice required
Teeth with poor prognosis
Significant patient or parental concern
Already wearing appliances
Second opinion (please give details)
Other Option (please give details)

Tick reason for early referral (must be completed if patient is under 10)

Incisor in crossbite with mandibular displacement
Overjet > 8mm
Extra teeth (supernumerary)
Missing teeth (hypodontia)
Teeth of poor prognosis
Upper canine tooth which cannot be palpated at 10 years
Other (please give details)

Any relevant medical / dental information

DPT radiograph taken within last 2 years? If yes, please upload the file (size not more than 20 MB).
Would you like the practice to arrange orthodontic extractions if needed?
Which Practice ?
Which Orthodontist?
No Preference