New Patient Registration Form

48 Woodberry Grove, London N4 1SN www.manorortho.co.uk

Tel: 0208 800 8581 Fax: 0208 802 2403

Email: Manor.clinic@nhs.net

Patient's Details

Patient's Name *

First Name Last Name

Patient's Address: *

Street Address

City

Post Code

Date of Birth *

Day Month Year

Gender *

Male Female

Patient's Tel

Patient's Mobile

SMS will be sent for confirmation

Relevant Medical and Dental History

Please specify reason for (self) referral

Is this an NHS or Private Referral

NHS Private

If an NHS Referral, please confirm that the Dental Health Component of the Index Of Orthodontic Need (IOTN) is 4 or 5. If the score is 3, the patient may qualify if the Aesthetic Component of the IOTN is 6 or above (please search on internet for images of Aesthetic Component of IOTN and score accordingly). IOTN's Dental Health Component Scores 1 or 2 for the Dental Component can only be treated on private basis

IOTN 5 (Overjet of over 9mm/ Missing teeth at least one tooth per quadrant/ Impaction of tooth due to crowding, displacement or pathology/ Reverse Overjet of 3.5mm With Speech and masticatory problem/ Submerged deciduous tooth/ Cleft lip & palate) IOTN 4 (Overjet between 6-9mm/ Overbite is increased, complete AND traumatic/ Reversed Overjet greater than 3.5mm/ Crossbite greater than 2mm/ Displacement of tooth greater than 4mm to neighbouring tooth/ Open bite greater than 4mm/ Missing tooth or teeth/ Crossbite lingual or posterior with no functional occlusion/ Reverse Overjet between1-3.5mm WITH speech or masticatory problems/ Partially Impacted or tipped tooth/ Extra tooth IOTN 3 AND Aesthetic Component of 6 or above (Overjet of 3.5-6mm with incompetent lips/ Reverse overjet of 1-3.5mm/ Displacement of tooth between2-4mm/ Open bite between 2-4mm/ Overbite is increased, complete Without trauma/ Crossbite anterior or posterior leading to a dispacement of between 1-2mm

Referring Dentist's Details

Dentist's Name

First Name Last Name

Practice Name

Practice Tel

Practice Address:

Street Address

City

Post Code

Dr's Email Address

You can upload digital radiographs, photographs or scanned documents with this referral by clicking on the 'Upload files' button below, selecting my computer and choosing the relevant files