Popular treatments
Teeth straightening
Other services
Referral type* I am a dentist referring a Private patient I am a patient referring myself (only available to over 18's)
Preferred Title (eg Mr, Mrs, Miss etc) Dr Miss Mr Mrs Ms
First name
Last name
Date of birth
NHS number
Home phone number
Mobile phone number
Email
Address line 1
Address line 2
Town
County
Postcode
What dental treatment are you interested in?
GDP name
GDC number
Practice name
Referral date
Is your referral urgent? Yes No
Post code
NHS or Private? - Please note we only accept children (under 18 years) as NHS patients. Adults (over 18 years) are seen as private patients. NHS Private NHS - discuss options with patient
Please select reason for referral Significant orthodontic abnormality Extraction advice requiredifvisible Teeth with poor prognosis Significant patient or parental concern Already wearing appliances Second opinion (please give details) Other (please give details)
Second opinion details
Other details
Please select reason for early referral (must be completed if patient is under 10) Incisor in crossbite with mandibular displacement Overjet > 8mm Extra teeth (supernumerary) Missing teeth (hypodontia) Teeth of poor prognosis Upper canine tooth which cannot be palpated at 10 years Other (please give details)
Please list any relevant medical / dental information
DPT radiograph taken within last year? Yes No
Would you like the practice to arrange orthodontic extractions if needed? Yes No
Which orthodontist would you like your patient to see? No Preference Preferred Orthodontist
Please supply their name
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