ORTHODONTIC PROBLEM: Please give as much detail as possible Overjet problem: OJ = mm Overbite problem: Crowding: Impacted teeth / submerged teeth: Missing teeth: Other: RADIOLOGY I enclose radiographs taken at the practice YES NONE TAKEN (please circle): (indicate below) OPG Lateral Ceph Occlusal view IOPA Other *Please note that radiographs sent to the hospital must be of excellent quality for diagnosis if copies are – sent please ensure they are printed out on high quality photographic paper and landscape view. Radiographs that are received which are not of sufficient quality for diagnosis may result in the referral being returned back to the practitioner. I confirm that the above information is accurate to the best of my knowledge: PRINT NAME: SIGNATURE: JOB TITLE: Date: PRACTICE ADDRESS: PLEASE SEND TO: SPECIALIST PRIMARY CARE ORTHODONTIC SERVICE, PRINCESS ALEXANDRA WING KINGSTON HOSPITAL, GALSWORTHY ROAD KINGSTON-UPON-THAMES SURREY, KT2 7QB FAX: 020 8934 3272
ORTHODONTIC PROBLEM: Please give as much detail as possible Overjet problem: OJ = mm Overbite problem: Crowding: Impacted teeth / submerged teeth: Missing teeth: Other: RADIOLOGY I enclose radiographs taken at the practice (please circle): YES (indicate below) NONE TAKEN OPG Lateral Ceph Occlusal view IOPA Other *Please note that radiographs sent to the hospital must be of excellent quality for diagnosis – if copies are sent please ensure they are printed out on high quality photographic paper and landscape view. Radiographs that are received which are not of sufficient quality for diagnosis may result in the referral being returned back to the practitioner. I confirm that the above information is accurate to the best of my knowledge: PRINT NAME: SIGNATURE: JOB TITLE: Date: PRACTICE ADDRESS: PLEASE SEND TO: SPECIALIST PRIMARY CARE ORTHODONTIC SERVICE, PRINCESS ALEXANDRA WING KINGSTON HOSPITAL, GALSWORTHY ROAD KINGSTON-UPON-THAMES SURREY, KT2 7QB FAX: 020 8934 3272