This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Why do you feel the patient needs hospital based orthodontic management?
- Orthodontic / Minor oral surgery
- Orthodontic / Restorative
- Orthodontic / Orthognathic (jaw) surgery
- Cleft lip / palate
- Orthodontic / paediatric dentistry management
- Special needs patient
- Second opinion
Reason for Referral: [Text]
Priority: [Routine]
Date of Onset: [Date]
Has the patient previously attended the department to which they are being referred?
- Yes
- No
- Don’t know
Has the patient previously attended any NHS Lanarkshire hospitals for treatment?
- Yes
- No
- Don’t know
Please provide details of previous admissions or attendances: [Text]
Does the patient have any special requirements, e.g. disability, autism, etc.:
- Yes
- No
Please provide details of special requirements: [Text]
Orthodontics Referral Guideline