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Referring Practice Information
Referring Doctor/Team Member Name
Practice Name
Referring Practice/Friend's Phone Number
Practice Email Address
Patient Information
Patient First Name
Patient Last Name
Patient Date of Birth
mm-dd-yyyy
Parent/guardian name (optional)
Patient Email
Patient Phone
Nature of referral
Which one does best describe the patient? *
Select one
Kid
Teen
Adult
Referring the patient for
Kid Orthodontic Evaluation
Early Orthodontic Care (Phase I/Interceptive)
Teen Orthodontic Consultation
Adult Orthodontic Consultation
Clear Aligner Therapy
Pre-prosthetic / Pre-implant Orthodontic Treatment
Corrective Jaw Surgery
Consultation on Sleep Disorders
The Main Concern (select the most important one)
Crowding
Crooked teeth
Cross-bite/ functional shift
Underbite
Spacing
Impacted teeth
Deep overbite
Openbite
Habits (e.g.,thumb sucking)
Speech concerns
Growth/ skeletal imbalance
Jaw bone(s) problems
Airway/ breathing concerns
Is Patient Cleared for Orthodontic Treatment?
Yes
No
Last Dental Visit Date
mm-dd-yyyy
Please provide any additional information here.
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