ORTHODONTIC REFERRAL FORM
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;
2. Patient must meet the Index of Orthodontic Need (IOTN) requirements 3, 4 or 5 with an
aesthetic component ≥6
(Ortho referral quick reference sheet.pdf);
3. All sections of the form completed;
4. Copy of orthopantomogram (OPG) enclosed (if available).