Online specialist referral form

At Melton Orthodontics, we are pleased to accept referrals from dental practices throughout the UK for all types of orthodontic procedures. From the 1st April 2018 however, NHS England require dentists to refer patients for NHS orthodontic treatment through the Referral Management Service (RMS). For more information about this facility, please either contact your Area Team or call us here at Melton Orthodontics on 01664 481048.

If you are a dentist and would like to refer an orthodontic patient to us for private treatment - simply complete the online form below and a member of our team will arrange an appointment for your patient and notify them by post. Please be sure to include your reason for referral. Alternatively, you can download the Specialist Dental Referral Form - pdf version, by using the button below and post it to us, enclosing any x-rays, covering letters or further necessary information.

Patient details

Referring dentist details

Further details

Is the patient over 10 years old (under 10s seen for specific clinical reasons only)
Is the patient motivated to undergo orthodontic treatment?
Is the patient dentally fit at the time of referral?
Is the oral hygiene excellent?
Is the patient in /very nearly in the permanent dentition?
Has the patient had a previous orthodontic assessment or treatment?

Clinical Information - please tick one or more or provide IOTN

Overjet

6-9mm      > 9mm      Reverse overjet <-1mm

Overbite

Deep or potentially traumatic      Extreme lateral or anterior open-bites (>4mm)

Crowding/Spacing

Moderate crowding (2-4mm contact point displacement)      Severe crowding (4mm or more contact point displacement)      Generalised spacing

Hypotondia

Up to one tooth missing in any quadrant      More than one tooth missing in any quadrant     

Canines

Erupted and aligned      Erupted and crowded      Unerupted and palpable

Other clinical features

Unerupted / non-palpable canines      Ectopic/Impacted teeth      Crossbites anterior or posterior (displacement over 4mm)

IOTN

IOTN DHC5      IOTN DHC4      IOTN DHC3 AC 6-10

Referral requirements

Tick all that apply

Private Orthodontics and Metal Braces      Radiance Clear Ceramic      Incognito Braces
Incognito Lite Braces      Invisalign Braces      Damon Braces

For further information about how we use your data, please see our privacy policy