Referring dentist's name & address

Name
DOB
Address
Email

Patient information

Patient name
Name of parent/guardian
DOB
Age
GenderMaleFemale
Address
Postcode
Telephone
Referral to
Good oral health?YesNo
If ‘No’ is checked, please justify the reason for referral.

Presenting problem

Indicate the main presenting problem only by ticking one of the options on the right hand side.

Increased overjet

Overjet 9+ mm - age 10+ (refer to specialist practice)YesNo
Overjet 6-9mm - age 10+: (refer to specialist practice)YesNo
Overjet under 6mm - any age: (referral not indicated at this time)YesNo

Incisor crossbite

Anterior crossbite - age 7+ (refer to specialist practice)YesNo

Crowding

More than 4 deciduous molars still present (keep under review in practice)YesNo
Marked crowding or irregularity (refer to specialist practice)YesNo
Mild crowding with significant aesthetic detriment (refer to specialist practice)YesNo
Mild crowding (referral not indicated at this time)YesNo

Upper canine(s)

Not palpable buccally - age under 10 (keep under review in practice)YesNo
Not palpable buccally - age over 10 (refer to specialist practice)YesNo
Unerupted - age 12+ & C/C's retained (refer to specialist practice)YesNo
Mild crowding (keep under review in practice)YesNo

Class II division 2 malocclusion

Class II division 2 malocclusion - late mixed dentition preferred (refer to specialist practice)YesNo

Hypodontia

Not more than 1 tooth absent per quadrant (ignore 8's) (refer to specialist practice)YesNo
More than 1 tooth absent per quadrant (ignore 8's) (refer to specialist practice)YesNo

Cleft lip and palate, Syndromes, medical history complicating treatment (refer to hospital service)Problems likely to require specialist surgical or restorative care (refer to hospital service)Malocclusion associated with skeletal discrepancies or facial asymmetry (refer to hospital service)Problems not covered above (refer to specialist practice)

Radiographs

Have any radiographs been taken within the last 12 monthsYesNo

Radiographs sent in

OPGYesNo
Intra-oralsYesNo

Make a referral