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Sharrow Dental Practice - Orthodontic Referral Form

Patient Name*
Date of Birth*

DD
MM
YYYY
Address*
Post Code*
Phone*
Section Two – Details of Referrer
In-house referral?
- Yes
- No
Name
Email Address*
Registration Number*
Date
Date Format: MM slash DD slash YYYY
Section Three – Referral Details
Type of Referral
OPG enclosed?
- Yes
- No
Has this patient been referred before for NHS orthodontic treatment?
- Yes
- No
Reason for referral:
- Standard Referral
- Second Opinion
- Transfer of Care
- Dispute
Oral Hygiene?
- Poor
- Fair
- Good
Section Four – Referral Criteria (IOTN)
IOTN GRADE 5 – PATIENT IN NEED OF TREATMENT
- None
- 5a – Increased overjet > 9mm
- 5i – Impeded eruption (crowding, displacement, supernumerary, retained deciduous teeth, pathology)
- 5m – Reverse overjet >3.5mm with reported masticatory or speech difficulties
- 5m – Reverse overjet >3.5mm with reported masticatory or speech difficulties
- 5m – Reverse overjet >3.5mm with reported masticatory or speech difficulties
- 5p – Defects of cleft lip or palate or other craniofacial abnormalities
IOTN GRADE 4 – PATIENT IN NEED OF TREATMENT
- None
- 4h – Less extensive hypodontia with ortho/restorative implications
- 4a - Increased overjet 6mm - 9mm
- 4b – Reverse overjet >3.5mm with no reported masticatory or speech difficulties
- 4m – Reverse overjet 1-3.5mm with reported masticatory or speech difficulties
- 4c – Anterior or posterior crossbites with >2mm discrepancy between RCP and ICP
- 4l – Posterior lingual crossbite with no function
- 4d. Severe contact point displacements >4mm
- 4e. Extreme lateral or anterior open bites >6mm
- 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
IOTN GRADE 3 – BORDERLINE NEED. TO BE ASSESSED FOR ELIGIBILITY.
- None
- 3a. Increased overjet 3.5mm - 6mm with incompetent lips
- 3b. Reverse overjet 1mm - 3.5mm
- 3c. Anterior or posterior crossbites with 1mm - 2mm discrepancy between RCP and ICP
- 3d. Contact point displacements 2mm - 4mm
- 3e. Lateral or anterior open bite 2mm - 4mm
- 3f. Deep overbite complete to gingival or palatal tissues but no trauma
Aesthetic component (1-10)
IOTN N/A
- IOTN N/A – Other reason for referral (e.g. advice regarding doubtful prognosis teeth following trauma to permanent dentition or caries experience). Please justify.
Justify
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