Completion of Active Orthodontic Treatment Form

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Provider Information

Name | Provider Number | Mailing Address:

Client Information

Name | Client ID Number | Mailing Address | Date of Birth: (Day/Month/Year)

Date active orthodontic treatment started (Day/Month/Year):

Date active orthodontic treatment completed (Day/Month/Year):

Was the original orthodontic treatment plan changed: YES | NO
If yes, please explain:

Were the objectives of the orthodontic treatment plan accomplished? YES | NO
If no, please explain:

Were retainers inserted? YES | NO
If no, please explain:

Projected duration of retention phase of orthodontic treatment?

Does the client require any additional dental services (restorative, periodontal etc.)? YES | NO
If yes, please explain:

I confirm that the above information is complete and accurate.
X
Provider signature

Date (Day/Month/Year)