Dental Referrals Under 18 – DB Orthodontics South Croydon

Pre Appointment Assessment - Patient

Below you will find our online patient pre appointment assessment form, it will need to be signed individually during the course of your treatment.

Dental Beauty Orthodontics (Under 18) Pre Assessment Questionnaire

Welcome to Dental Beauty Orthodontics, the UK’s longest established family-run Orthodontic Practice. We are celebrating 52 years of creating beautiful, healthy smiles.

With over 110,000 patients served, we are excited to guide your child towards achieving their best possible smile.

Your role is crucial, as government regulations require individuals under 18 must have adult supervision in navigating the initial stages of the orthodontic pathway.

Completing the form will take approximately 5-10 minutes. If you have a camera phone ready that will be useful as we will be asking you to take a few photos for us.

This information is vital for us to schedule your child’s appointment accurately and to tailor their treatment to the correct team.

We are happy to support you every step of the way on your child’s orthodontic journey.

Your Choices
At Dental Beauty Orthodontics we are committed to providing exceptional orthodontic care tailored to the unique needs of each patient. Whether through the NHS or via our Independent Treatment pathways, we offer a broad spectrum of cutting-edge orthodontic solutions.

Unfortunately, not all children qualify for NHS orthodontic treatment, as eligibility is determined by strict criteria based on dental health needs rather than cosmetic concerns. At your appointment, your Orthodontist will let you know whether your child qualifies for NHS treatment. If your child doesn’t qualify for NHS treatment, then we offer affordable private solutions for children. Below we have detailed an overview of the service provided under each option. Your Orthodontist can discuss this in more detail with you at your appointment.

	NHS	Independent Treatment Pathway
Treatment For All Cases	No	Yes
Brace Types	Traditional fixed braces	A range of solutions including invisible braces
Waiting Times	9–12 months	No waiting time
Appointment Scheduling	Monday–Friday 9–4	Early and late appointments available
Payment Plans	N/A	Yes
Aftercare	No aftercare provided	Retainers provided to help keep teeth in place

What pathways are you considering at this stage?

Patient's name

Date of birth

Address

Gender

Patients Ethnicity

Patients NHS Number

Could you let us know the reason (s) why you would like to meet with us?

Name of Parent or Guardian

Parent/Guardian contact email

Mobile number

Landline number

Does patient live with Parent/Guardian

Name of second parent/guardian

Second parent/ guardian email

Who is the primary decision maker?

Is there anything you would like to mention about family status?

Name of Dentist

Name of Practice

Practice Address

Did the dentist refer you or did you come another route?

When were you last at the dentist?

If you do not have a dentist or are considering moving would you like more information about our general dentistry services?

Is the patient currently experiencing dental pain or discomfort?

What does the patient want to change about their smile?

Do you have any other comments or concerns about the teeth and jaws that you would like to discuss?

Is the patient in good health?

If No please provide details here

Have they had a serious illness, operation, or been hospitalized in the past 5 years?

If Yes please provide details here

Please send us some images of the smile

5 photos in the mouth (see the picture or video below as a guide) and one photo of you smiling

It would be extremely helpful if you could take 5 intra oral photos of your smile. It will help us evaluate you in detail and direct you to the right clinical team from the outset. The pictures are best taken with a Smartphone by a friend or family member as some pictures need you to retract the lips . See the photos above which give an example of what we want. There is also a short video you can watch.

Please include a 6th photo which is just a headshot photo of the patient smiling from ear to ear. Once they are taken just drag and drop and upload them into the next section.

Please use this facility to attach relevant case files (patient notes, x-rays etc.) (max file size 2mb)

Name of person sending form

Date Of Submission

Acknowledgement

I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of my errors or omissions that I may have made in the completion of this form.

Terms

I agree to the Practice terms & conditions and have read the document on Informed Consent.

Consent

I consent to having an Orthodontic assessment and investigations prescribed by the clinical team to ensure a comprehensive diagnosis and treatment plan can be established. This includes photos, digital scan of teeth and necessary radiographs.

Agreement

I have read and agree to the Patient Partnership Document

NHS Notification

I understand that the NHS does not fund treatment for all patients and for under 18s is reliant on the IOTN Assessment.