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Tel: 02920 233 528 Fax: 029 20 225 638
     
 

Orthodontic Referral / Cyfeired Orthodontig

 
     
  Please Click Here to download our orthodontics referral form, or complete the online form below.  
     
 
Only Referrals made on this form will be accepted for NHS Orthodontic treatment in South East Wales
Referring Practitioner:
Name:
Email:
Telehone:
Practice:
Date of referral:
Performer Number:
Patient Details:
Name:
D.O.B:
Telehone:
Address:
SECTION 1 - BASIC INFORMATIONIf you are referring for treatment you will need to provide all the details below and complete SECTION 2.
Is the patient motivated to undergo orthodontic treatment (wear appliance) ?
Is the patient dentally fit at the time of referral ?
Is oral hygiene 'good' to 'excellent' ?
Have the patient and parents been advised that they may not be eligable for NHS treatment ?
Please do not refer for orthodontic 'treatment' ot 'treatment planning' if you cannot tick 'Yes' against all of the above.
Is the patient in / very nearly in permanent dentition ?
If patient is in primary dentition or early mixed dentition, please state reason for early referral:
Referral For: (Please select one from the choices below and ensure all radiographs are attached)
Please use the below to attach any relevant files:

SECTION 2 - THIS SECTION MUST BE COMPLETED IF YOUR REFERRAL IS FOR TREATMENT
Features in BOLD and UPPERCASE should be referred to a consultant in orthodontics in your local hospital. Cases in bold may be accepted by specialist practice or by the orthodontic department at your local hospital. Referrers are advised to liaise with their orthodontic providers before referring such cases.
Overjet
Overbite
Crowding / Spacing
Hypodontia
Other Clinical Features
IOTN (If known)
SECTION 3 - ADVICE AND / OR TREATMENT PLANNING
If the patient is being referred for advice and/or treatment planning, it is assumed that you will be providing the required NHS treatment to the patient. Please indicate the nature of the advice required and/or your provisional treatment plan (to be confirmed by the specialist/consultant) e.g. URA to correct crossbite or space maintainer:
SECTION 4 - OTHER INFORMATION
Relevant Dental History (if urgent please specify):
Relevant Medical History and GP's name:
Relevant Social History:
I’d like to be informed of exclusive offers and other practice information YES

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