Doctor Name *

First Name

Last Name

Patient Name *

First Name

Last Name

Patient Date of Birth

MM

DD

YYYY

Parent/Guardian Name

First Name

Last Name

Patient Phone Number *

(###)

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Please evaluate for the orthodontic correction of:

Crowding

Spacing

Crossbite

Functional shift

Oral habit

Tongue thrust

Overjet

Impacted tooth

Space maintenance

Pre-restorative alignment

Other (please provide additional info in comments section)

Restorative and Periodontal Status:

This patient has no caries or periodontal disease and is ready to start orthodontic treatment as needed.

This patient still needs to complete restorative work before starting orthodontic treatment.

This patient still needs to complete periodontal work before starting orthodontic treatment.

Please call before proceeding with treatment.