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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
- 5s – Submerged teeth
- 5h – Severe hypodontia, more than 1 tooth missing in each quadrant
- 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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Sharrow Dental Care

Moulsham Street
Chelmsford
Essex
CM2 0JG

01245 354046

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Opening Times

Monday: 9AM-5PM
Tuesday: 9AM-5PM
Wednesday: 9AM-5PM
Thursday: 9AM-5PM
Friday: 9AM-5PM
Saturday: 9AM-1PM
Sunday: 9AM-1PM

We are now accepting new NHS patients for adults as well as children.

Any new patients wanting to join on an NHS basis will be offered an appointment with our Dental Therapist, Irmina, who is based at The Annexe on Moulsham Street.

Dental Therapists can complete most Dental treatments, and complex treatment in conjunction with a Dentist.

Please be aware not all treatment is available on the NHS. This will be discussed with you at your initial NHS Examination.

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Book An Appointment Book For Sharrow-The Annexe

Sharrow Dental Practice - Orthodontic Referral Form

Section Two – Details of Referrer

Section Three – Referral Details

Section Four – Referral Criteria (IOTN)