Introducing: Date of Birth:
Patient will call to schedule Orthodontic Consultation CORINTHTROPHY CLUB
Please contact patient to schedule Orthodontic Consultation
Parent/Guardian Name: Phone:
Clinical Finding
CrossbiteOverbiteCrowdingOverjetImpacted TeethPre-Prosthetic AlignmentMinor Tooth MovementSpace MaintenanceMissing TeethSpacingOpen biteOral Habit/Tongue Thrust
Other:
This patient is being referred for:
1st Orthodontic Consult (7 and up)Early Interceptive Treatment (7-9 1/2yrs)Dentofacial Orthopedics (7-9 1/2yrs)Comprehensive Orthodontics (11 and up)Habit Correction TreatmentPre-Prosthetic/Implant Site DevelopmentAirway Development
Comments:
Please call me before proceeding with treatment. I have emailed radiographs for your evaluation.
Referring Dr.: Date: Referring Dr. Phone #:
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