Isle of Wight Primary Care Trust
Total Page：16
File Type：pdf, Size：1020Kb
A Collaboration between Portsmouth City, Southampton Enclosure 3 City, Hampshire Primary Care Trust (PCTs)
REFERRAL FOR NHS ORTHODONTIC ASSESSMENT Please complete this form for any patient in need of NHS orthodontic treatment that meets the following criteria: 1. Patient to be less than 18 years of age at the point of referral (see guidance) 2. Patient must meet the requirements of the Index of Treatment Need (IOTN) 4, 5 and 3 with an aesthetic component of 6 or above (SCAN) to be eligible for NHS treatment. Please complete all sections of this referral form. Please include a copy of an OPG (if available) – Please see Section Five Please note that you must complete all sections of this form. If all sections are not completed, the form will be returned to you and the patients treatment will be delayed. Please see accompanying notes for further details. SECTION ONE – PATIENT DETAILS
Patient Name Date of Birth
Address
Contact Tel(s):
Post Code
GP Name and Address
SECTION TWO – DETAILS OF REFERRER
Name of Referrer Practice Stamp (Address and Contact Tel):
Signature
Date
SECTION THREE – REFERRAL HISTORY
Has this patient been referred before for NHS orthodontic treatment?
YES No
If Yes, please specify where
SECTION FOUR – CHOICE OF PROVIDER
Has this patient or referrer expressed a preference of Provider?
Yes No
If Yes, please provide details (who and why)
Please note: If the patient or referrer does not express a preference, the patient will be allocated to an appropriate Provider with capacity at that time. If the patient or referrer has expressed a preference this Provider may not be suitable and if the wait is above 18 weeks you may be contacted to discuss other alternatives.
SECTION FIVE – REASON FOR REFERRAL
Please provide below any additional information to support the referral (please include the date of GDP appointment when possible need for orthodontic treatment identified)
OPG Enclosed (please tick) Standard Referral Second Opinion Transfer of Care Dispute OFFICE USE ONLY: REFERENCE NO:
CONTINUATION SHEET – PAGE 2 OF 2 Page 1 of 2 Patient Name Date of Birth CRITERIA - Please tick one box only. Start at the top and work down until you identify the component that best fits the patient being referred: Grade 5 – Patient in Need of Treatment 5i Impeded eruption of teeth (excluding third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth & any pathological Patient to cause be referred 5m Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties to Primary Care for 5a Increased overjet greater than 9mm assessment
5h Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics Patient to 5c Defects of cleft lip or palate and other craniofacial anomalies be referred to Secondary 5e Submerged deciduous teeth Care for assessment
Grade 4 – Patient in Need of Treatment 4h Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for a prosthesis 4a Increased overjet greater than 6mm but less than or equal to 9mm
4b Reverse overjet greater than 3.5mm with no masticatory or speech difficulties 4m Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory and speech difficulties 4c Anterior or posterior crossbites with greater than 2mm discrepancy between retruded contact position and intercuspal position Patient 4l Posterior lingual crossbite with no functional occlusal contact in one or both buccal likely to be segments. seen in Primary 4d Severe contact point displacements greater than 4mm Care 4e Extreme lateral or anterior open bites greater than 4mm
4f Increased and complete overbite with gingival or palatal trauma
4t Partially erupted teeth, tipped and impacted against adjacent teeth 4x Presence of supernumerary teeth
Grade 3 – Patient may not need to be seen. Referral to be assessed re eligibility for treatment – Borderline Need Please tick box for Dental Health Component & score between 1-10 for the Aesthetic Component (SCAN).
m
a scan E
a
3a Increased overjet greater than 3.5mm but less or equal to 6mm with incompetent lips s
l
y
i
s
g
e
n
i
b
s
o
i scan s
3b Reverse overjet greater than 1mm but less than or equal to 3.5mm l
t
i
e
t
y
b
d
e
t
w
o
e
i
b scan t
l
3c Anterior or posterior crossbites with greater than 1mm but less than or equal to 2mm h
i
e
g
i
n
i
r
b discrepancy between retruded contact position and intercuspal position e
P
l
v
e
r
i
scan i
e
3d Contact point displacements greater than 2mm but less than or equal to 4mm m
f
w
o
a
e
r
r
d
y
N
.
C
scan H 3e Lateral or anterior open bite greater than 2mm but less than or equal to 4mm P
a
S
a
r
t
e
t
i
e
r
.
e
n
P
scan a
t
3f Deep overbite complete on gingival or palatal tissues but no trauma a
t
t
m
t
o
i
e
e
b
n
n
e
t
t
. Other Reason for Referral – IOTN N/A Other Reason for Referral (e.g. Caries of doubtful prognosis) PLEASE SEND COMPLETED FORMS TO: Orthodontic Central Referral Centre, Fanshawe Wing, Level B, Royal South Hants Hospital, Brintons Terrace, Southampton, SO14 0YG OR FAX TO: 023 8063 8141. Any queries please telephone: 023 8071 6695
Page 2 of 2