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Sutton Orthodontics logo

103 Brighton Road, Sutton, London, SM2 5SJ

Referral Form

Patient’s Information

Dentist’s Information

Pre-referral Checklist

Patient motivated to undergo orthodontic treatment
Oral health stable and oral hygiene acceptable for orthodontic treatment
Patient in permanent dentition (If not, please give reason for referral below)
Patient and parents/carers have been advised they may not be eligible for NHS treatment
Copies of relevant/recent radiographs attached

Referring for Treatment

Maximum file size: 25MB

Maximum file size: 25MB

Crossbites
Associated displacement on closure
Overbite

Referring for Interceptive Treatment
Sutton Orthodontics logo

103 Brighton Road, Sutton, London, SM2 5SJ