duanorthodontics.com-aao_transfer

Rows	Type	Manufacturer
1

Date bands and/or brackets placed

Rows	Max	Mand	Bonding Agent	Cementing Agent
1

Rows	Max	Mand
1

Clear tray appliance:

Rows	Manufacturer	Total trays	Trays delivered	Change interval	Case/Patient number
1

Rows	Active	Extras
Fees:

Rows	.
Third party payment
Total charges before transfer
Total amount paid before transfer
Unpaid amount still owed transferring office
Balance of original quoted fee not yet charged
or overpaid at transfer

This patient/parent has been advised that orthodontic treatment fees vary widely throughout the country and the world and it is reasonable for them to expect that a transfer may increase treatment fees and may involve changes in payment policies. For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.

AVAILABLE RECORDS FOR TRANSFER

Check appropriate status of records:

Rows	Yes	No
Record duplicates sent upon request (may be an additional charge to patient)
Records enclosed
Records sent under separate cover

Signature (Orthodontist)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I authorize Dr. First Name Last Name to release all records of (patient’s name) for the purpose of continuation of treatment by Dr. First Name Last Name (new provider’s name).
Signature (Patient or Guardian)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Print Name

First NameLast Name
Relationship to Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: