Guidence FP170 A4 - NHS Business Services Authority

Part 5To be completed on assessment or at the fitting of the first appliance. Parts 1,2, (3 if appropriate), 4 and 8 must alsobe completed.Assessment & Review – Cross this box if an assessmenthas been performed, NHS orthodontic treatment isindicated, but the patient is not ready to start. A dateof assessment and IOTN score must be present. If theIOTN score is 3, the Aesthetic Component must alsobe completed. For a fee paying patient the Band 1charge is levied.Assessment & Refuse Treatment – Cross this box if anassessment has been performed but NHS orthodontictreatment is deemed unnecessary or inappropriate. Adate of assessment and IOTN score must be present. Ifthe IOTN score is 3, the Aesthetic Component must alsobe completed. For a fee paying patient the Band 1charge is levied.Assessment and Appliance Fitted – Cross this box if anassessment has been performed and an orthodonticappliance has been fitted. A date of assessment, dateappliance fitted and IOTN score must be present. If theIOTN score is 3, the Aesthetic Component must also becompleted. For a fee paying patient the Band 3 chargeis levied. If a patient commences a course of treatmenta second form must be submitted on completion ortermination of treatment.IOTN – Enter the IOTN Dental Health Component. If thevalue is 3, the Aesthetic Component must also becompleted.Aesthetic component – Enter the IOTN AestheticComponent.IOTN not applicable – Cross this box if an IOTNassessment is not possible. For example, transfer caseswith fixed appliances in situ.Date of Referral – Enter the date the referral wasreceived.Date of Assessment – Enter the date of assessment onall assessment forms.Date Appliance Fitted – Enter the date the first appliancewas fitted for this course of treatment. The DateAppliance Fitted must be on or after the Date OfAssessment.Part 6To be completed on completion or termination of orthodontic treatment. Parts 1,2,4 and 8 must also be completed.Treatment abandoned – patient failed to return – Crossthis box if the active treatment was abandoned becausethe patient failed to return. A date of last visit andIOTN score or IOTN not applicable must be present.Treatment abandoned – patient requested – Cross thisbox if the active treatment has been abandoned at thepatient’s request. A date of last visit and IOTN score orIOTN not applicable must be present.