36-38 FERRING STREET, FERRING, WORTHING BN12 5HJ

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01903 249101

Orthodontic Referral

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01903 249101

Thank you for choosing to refer your patient to our orthodontic team. We value our collaborative relationships with dental colleagues and are committed to providing high-quality, patient-centred orthodontic care. Please complete the referral form below with as much detail as possible to ensure a smooth and efficient assessment process.

Image of dentist performing oral surgery

Orthodontic Referral Form

 

Please complete the form below to refer patients.

*Indicates required field

Treatment required

Radiographs included

New Field

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Is your patient a regular attender to the hygienist?

If 'yes', frequency of hygiene attendance?

I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

Practitioner Authorisation and Responsibility Statement

I confirm that:

  • The patient has been examined by me and is dentally fit for orthodontic assessment.
  • Periodontal health has been evaluated, and any required stabilization has been completed or is being managed.
  • All relevant clinical information provided is accurate to the best of my knowledge.

By submitting this referral, the referring dentist acknowledges that:

The practice will assess the patient and recommend treatment based on clinical findings and suitability.

Final treatment planning decisions rest with the treating dentist in accordance with professional standards.

The referring dentist retains responsibility for the patient’s routine dental care, periodontal maintenance, and any non-orthodontic treatment needs.

The practice accepts no liability for pre-existing dental conditions or incomplete information provided at the point of referral.