--- title: "Orthodontic Letters and Reports UK | Your Rights to Copies (2026)" url: https://virtualconsultant.online/guides/orthodontic-letters-reports-uk description: "What referral letters, progress reports and discharge summaries contain, and your right to access them under UK data law." updated: 2026-08-17T00:00:00Z publisher: Virtual Consultant Online --- Patient Rights Records UK GDPR # Orthodontic Letters and Reports: What They Contain and Your Right to Copies Throughout orthodontic treatment, a range of letters, reports, and clinical records are created. These documents record clinical findings, treatment decisions, and communications between clinicians. Understanding what these records contain and how to access them is an important part of being an informed patient in the UK. [Start Photo Assessment](https://virtualconsultant.online/evaluations/quote) [Compare Costs](https://virtualconsultant.online/costs) ## Types of orthodontic records and letters UK orthodontic practice generates several categories of written documentation throughout the referral and treatment cycle. These include referral letters from GDPs (general dental practitioners) to orthodontists, assessment or consultation reports generated after the initial orthodontic examination, progress notes recorded at each clinical appointment, correspondence letters sent between clinicians during treatment, and a discharge summary produced at the end of treatment. In NHS settings these documents follow fairly standardised formats; in private practice the content is similar but the format varies between practices. Each category of document serves a different clinical and medico-legal purpose. ## What a referral letter contains A GDP referral letter to an orthodontist typically includes the patient's name, date of birth, and NHS number (for NHS referrals), a brief clinical history including relevant medical conditions and medications, a description of the presenting dental complaint or malocclusion, the GDP's clinical findings such as IOTN score or specific features like overjet, crowding, or impacted teeth, and a statement of what the referring dentist is requesting — assessment, treatment, or advice. NHS referrals to community orthodontic services or hospital departments use specific referral forms and must meet IOTN thresholds to be accepted. The referral letter becomes part of the orthodontic clinical record. ## What an orthodontic assessment report includes After the initial assessment appointment, the orthodontist produces a record of their clinical findings. This typically includes the patient's medical and dental history, intraoral and extraoral clinical examination findings, study model or digital scan records, radiographic findings from OPT (dental panoramic) and lateral cephalometric radiographs where taken, photographs, an IOTN score, the proposed diagnosis, and the recommended treatment plan including appliance type, estimated duration, extraction requirements, and any specialist referrals. In NHS treatment the assessment also includes the index of treatment complexity, outcome, and need (ICON) and similar orthodontic indices. A copy of this report may be sent to the referring GDP. ## Progress notes and what orthodontists record At each clinical appointment the orthodontist or orthodontic therapist records progress notes. These note what was done at the appointment — wire changes, bracket bonding, adjustment of appliances — observations about tooth movement and compliance, any patient concerns raised, instructions given to the patient, and the plan for the next appointment. For aligner patients the current stage number, tracking assessment, and remote monitoring observations are typically recorded. Progress notes are often brief and use abbreviations, but they form the continuous clinical record of treatment and are central to any complaint or legal investigation regarding the treatment provided. ## Discharge summary contents At the end of orthodontic treatment, a discharge summary is produced. This documents the treatment completed, the appliances used, treatment duration, the outcome assessed against the original treatment plan, post-treatment IOTN or PAR (Peer Assessment Rating) score, retainer type prescribed, any complications that occurred during treatment, and instructions to the patient for retention. A copy of the discharge summary is typically sent to the referring GDP to inform their ongoing care. The discharge summary is an important document for any future clinician who treats the patient and for the patient's own records. ## Subject Access Request (SAR) under UK GDPR Under the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018, patients have the right to access all personal data held about them, including clinical records, letters, radiographs, photographs, and study models. This right is exercised by submitting a Subject Access Request (SAR) to the data controller — in most cases the practice principal or, for NHS hospital treatment, the relevant NHS trust. The SAR must be made in writing (email is acceptable), must identify the individual and the records requested, and does not require the patient to explain their reasons for the request. There is generally no fee for a SAR, though reasonable charges may apply for excessive or repetitive requests. ## 28-day response deadline Under UK GDPR, the data controller must respond to a SAR within one calendar month (approximately 28 to 31 days) of receiving the request. If the request is complex or there is a high volume of records, this can be extended by a further two months, but the patient must be notified of the extension within the first month. The response must provide copies of all requested personal data in an accessible format. Digital records are usually provided electronically; physical records such as plaster study models may require inspection at the practice rather than being posted. Failure to respond within the required timeframe is a breach of UK GDPR reportable to the Information Commissioner's Office (ICO). ## What to do if records are refused or incomplete If a practice fails to respond to a SAR, refuses to provide records without legal justification, provides incomplete records, or charges an unlawful fee, the patient has several options. They can write a formal complaint to the practice principal. They can refer the matter to the Information Commissioner's Office (ICO), which can investigate and take enforcement action. For NHS treatment, they can also escalate through the NHS complaints procedure. Exemptions from disclosure under UK GDPR are narrow — they include situations where disclosure would be likely to cause serious harm to the patient's physical or mental health, which requires a clinical assessment and cannot simply be used to withhold inconvenient information. ## Using records for second opinions and complaints Accessing orthodontic records is frequently sought by patients seeking a second opinion about ongoing treatment, patients who believe treatment caused harm and are considering a complaint or claim, and patients transferring to a new provider. Records are essential for continuity of care and for any formal complaint to the GDC (General Dental Council) or a clinical negligence investigation. For second opinions, providing the new clinician with the original assessment report, progress notes, and relevant radiographs allows them to give an informed view without repeating all initial investigations. Patients have the right to share their own records with whomever they choose. ## Useful related pages [Orthodontic Records UK](https://virtualconsultant.online/guides/orthodontic-records-uk) [Patient Rights in Orthodontic Treatment](https://virtualconsultant.online/guides/patient-rights-orthodontic-treatment-uk) [Orthodontic Consent and Patient Rights](https://virtualconsultant.online/guides/orthodontic-consent-patient-rights-uk) [Getting an Orthodontic Second Opinion](https://virtualconsultant.online/guides/orthodontic-second-opinion-uk) [Private Orthodontic Complaints UK](https://virtualconsultant.online/guides/private-orthodontic-complaints-uk) This guide is for general information only. It is not a diagnosis, treatment plan, or substitute for advice from a registered dentist or orthodontist. ### Compare next steps [Orthodontist Near Me](https://virtualconsultant.online/locations/orthodontic-treatment-near-me) [Clear Aligners Near Me](https://virtualconsultant.online/treatments/clear-aligners-near-me) [Invisalign Near Me](https://virtualconsultant.online/locations/invisalign-provider-near-me) [Browse Locations](https://virtualconsultant.online/locations) ### Ready for a clearer starting point? Upload guided photos and receive an indication of likely treatment options and pricing before booking appointments. [Get an Online Quote](https://virtualconsultant.online/evaluations/quote) ### Frequently Asked Questions Am I entitled to copies of all my orthodontic records? Yes. Under UK GDPR you have the right to access all personal data held about you, which includes clinical notes, letters, radiographs, photographs, and study models. You exercise this right by submitting a Subject Access Request to the practice. The practice must respond within one calendar month and generally cannot charge a fee for providing the records. How do I request my orthodontic records? Write to the practice — an email is sufficient — addressed to the practice principal or data protection officer, identifying yourself, the period of treatment, and the records you are requesting. State clearly that you are making a Subject Access Request under UK GDPR. Keep a copy of your request. The practice has one month to respond. Can a practice refuse to give me my records? Only in very limited circumstances. UK GDPR exemptions allow withholding information if its disclosure would be likely to cause serious harm to your physical or mental health, and this requires a clinical assessment. Practices cannot refuse simply because the records might be used in a complaint. If you believe your request has been unlawfully refused, you can report this to the Information Commissioner's Office. What is in an orthodontic discharge summary? A discharge summary records the treatment completed, the appliances used, the outcome, the final clinical assessment, any complications, the retainer prescribed, and instructions for ongoing retention. It is sent to your referring dentist and you can request a copy for yourself. It is useful when transferring to a new dentist, seeking a second opinion about relapse, or if questions arise about what was or was not done during treatment. How long must a dental practice keep my orthodontic records? NHS dental records must be retained for a minimum of 10 years from the end of treatment, or until the patient's 25th birthday if they were a child at the time of treatment — whichever is longer. Private dental practices are expected to follow equivalent standards. After the retention period, records may be destroyed, so it is worth requesting copies of key documents — particularly radiographs, photographs, and the discharge summary — while they are still held. Can I get my records sent directly to a new orthodontist? Yes, and it is usually the smoothest route. Ask your current practice to transfer the records directly to the new clinician rather than requesting copies for yourself and forwarding them — direct transfer between clinicians is routine, avoids format problems with large scan and X-ray files, and means the receiving orthodontist gets the originals at full diagnostic quality. Put the request in writing, name the receiving practice, and allow up to a month, which is the standard statutory response time. Explore your options Quick links Not sure where to start? Use these quick links to explore orthodontic treatments, typical costs, and helpful guides that explain what different options involve. Whether you're researching braces or clear aligners, comparing pricing, or just getting a feel for what comes next, you can browse at your own pace and come back when you're ready to request a quote. 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Upload guided photos and get a tailored recommendation for your teeth and bite. [Start Photo Assessment](https://virtualconsultant.online/evaluations/quote) [Find an Orthodontist](https://virtualconsultant.online/locations) Citation details Title Orthodontic Letters and Reports UK | Your Rights to Copies (2026) Publisher Virtual Consultant Online Published 2024-06-01 Updated 2026-08-17 URL [https://staging.virtualconsultant.online/guides/orthodontic-letters-reports-uk](https://staging.virtualconsultant.online/guides/orthodontic-letters-reports-uk)