Dentist NHS referral

All NHS referrals must be submitted on the Essex NHS Orthodontic referral pro-forma. Please ensure the form is completed in full, so that each case can be accurately assessed for its level of urgency.

All referrals are triaged and appointments are issued accordingly. If you’re unsure about any part of the referral, please don’t hesitate to contact our team for guidance.

Patient Information

Impacted/Ectopic teeth (Indicate) supporting radiograph must be attached
Upper Teeth →
Lower Teeth →
Overjet (Measured in mm) →
Overbite *
Crowding *
Spacing *
Missing teeth developmentally (indicate) supporting radiograph must be attached
Upper Teeth →
Lower Teeth →
Cross Bites
Radiographs attached: OPG/PERIAPICAL/OTHER
Radiographs or other attachments

For any photos, xrays or additional information you wish to submit alongside this referral, please upload here.
Accepted file types: jpg, gif, png, pdf.

Select Files

*By clicking ‘submit’ you are consenting to us replying, and storing your details. (See Our privacy policy).