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).

If any section of this form is incomplete it will be returned to you and the patient’s treatment will be delayed.
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