ORTHODONTIC REFERRAL FORM for Patients with IOTN 3.6 Or Above Who Have Never Started A

ORTHODONTIC REFERRAL FORM for patients with IOTN 3.6 or above who have never started a course of treatment, except when < 10 years old Patients Details NHS number Name Date of birth Sex M F Age Address Tel Mobile Town postcode Email Referring Practitioner Details Name Tel Practice name Mobile Address NHS Email

Town postcode Exam date Clinicians who are trained in IOTN may complete parts A,B or D then E . Those not IOTN trained should complete parts C or D then E

Part A IOTN referral. Enter IOTN dental health component (DHC) of patient 1 to 5 plus the qualifier a to x or in DHC qualifier part E the clinical reason for the referral. If DHC is 3 or less go to part B or D (see over leaf or the referral pack)

Part B IOTN 3.6 referral. To qualify for treatment at the minimum IOTN level the patient must have a DHC of 3 plus an aesthetic component (AC) of at least 6 with the correct qualifier. The AC is highly subjective, so only IOTN Ac qualifier certified clinicians should use this. Otherwise please use Parts C or D (see overleaf or the referral pack) Part C Clinical referral. You must check one of the features below and give a reason for your referral in part E. A patient displaying one of the clinical occlusal traits listed below should have a minimum IOTN (DHC) of at least 4. ( see overleaf or in the referral pack ) 1a Overjet >6mm but 1b if >10mm 2a Reverse overjet > 1mm with functional defects or 2b > 3.5mm 3. Traumatic overbite . 4 .Open bites>4mm 5. Ant /post x bites with > 2mm displacement 6 Crowded /malaligned teeth contact point displacement >4mm 7 Missing teeth 8 Supplemental teeth 9 Non palpable permanent canines aged >9 In one or more quadrants

10 impacted teeth inc. canines 11 infra occluding deciduous teeth 12. Possible surgical case Features explained over page

Part D referral for advice. Please tick this box Then indicate in part E the nature of the advice required. Referral for advice is acceptable, however in such cases there must be a clinical reason which is clearly demonstrated below and not patient /parent request. To support your case you should include where possible any models radiographs and photographs taken. Please attach as much information as possible so that the orthodontist can assess the advice needed for treatment under the NHS regulations.

Part E please complete this part for all referrals Last caries incident months ago. Current active caries no / yes If yes, explain below management plan indicating prognosis of teeth. Confirm by checking the box that the patient does not have .Confirm by checking the box that copy of the consent form has been a digit sucking habit and their oral hygiene is satisfactory. All the shared with the patient & parent /guardian and they are able to comply necessary prevention and advice indicated in Delivering Better with the conditions. They should understand what is generally involved Oral Health has been provided and that continuing care will be in orthodontic treatment and treatment is not guaranteed by this offered. referral Relevant medical history

Clinical reasons from parts A B C or D, comments on caries, oral hygiene and any additional information

Specialist I have read and understood the guidance notes for referral of this type Centre Practitioner’s signature Address

Town postcode Date Please ensure all required sections are complete, attach a medical history form (child version) if necessary, relevant radiographs and any additional letter or information you may wish to include. Paper only referral form O.R.F.p V 2.9 Designed by B. Hayes Aug 2015.