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Orthodontic Referral
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REFERRING OFFICE INFORMATION
Practice Name
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Referring Dentist
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Date
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PATIENT INFORMATION
Patient Name
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Telephone Number
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Date Of Birth
*
MM slash DD slash YYYY
EVALUATION
Evaluation
Impacted tooth/teeth
Crowding teeth
Spaced teeth
Missing teeth
Early or Interceptive Treatment
Overbite
Crossbite
Overjet
TMJ Dysfunction
Pre-Restoration Alignment
Tongue Thrust
Thumb Sucking
Alignment
Space Maintenance
Airway
SPECIFIC CONCERNS
Specific Concerns
DENTAL HISTORY
Does the patient have dental work that needs to be completed?
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Yes
No
If yes, please specify:
Panoramic radiograph available?
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Yes
No
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