Orthodontic Summary Sheet

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Section 1 Provider Information

Name & Mailing Address/Office Stamp:
Prescriber's Telephone:

Section 2 Patient Information

Patient's Name:
Surname Given Name(s):
Date of Birth:
Sex: M | F

Oral Hygiene:
Chief Complaint: Patient:
Chief Complaint: Parent/Guardian:

Skeletal and Soft Tissue/Dental Characteristics:

Special Features (Radiographical and Functional Analysis, Periodontal Treatment)

Treatment Objectives

Treatment Plan:

Active Treatment Time:

Retention Time:

Cost:

Date:

Provider's Signature:

I/we understand the nature of the proposed orthodontic treatment and the commitment required should this be approved.

Signature (Parent/Guardian):

Patient:

Confidential when completed