Orthodontic Treatment Summary and Consent Form
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Diagnosis
1. Facial profile
Please Select
a. Normal
b. Protrusive
c. Retracted
2. Jawbone class
Please Select
a. Normal
b. Top jaw ahead of bottom
c. Lower jaw ahead of top
3. Tooth class
Please Select
a. Normal
b. Top teeth ahead of bottom
c. Lower teeth ahead of top
4. Cross bite
Please Select
a. None
b. Single teeth
c. Group of teeth
5. Size of upper Jaw bone
Please Select
a. Normal
b. Constricted small
c. Large
6. Size of lower jaw
Please Select
a. Normal
b. Constricted small
c. Large
7. Upper tooth midline
Please Select
a. Centered
b. To the side
8. Lower midline
Please Select
a. In line with upper
b. Out of line with upper
9. Overbite
Please Select
a. Normal
b. Deep
c. Open
10. Overjet
Please Select
a. Normal
b. Upper teeth to far in front
c. Lower teeth to far in front
Treatment Recommendations
Phase 1
1. Functional appliance
Please Select
a. Single jaw expansion
b. Double jaw expansion
c. Appliance to move a jaw forward
d. No appliance
2. Functional appliance
Please Select
a. Fixed - stays in Mouth
b. Removable - come in and out
COSTS - for 1 appliance.
Phase 2
3. Braces or Invisalign
Please Select
a. Braces
b. Invisalign
4. Full braces
Please Select
a. Full case
b. Single Jaw
c. Only 6 teeth
COSTS - including initial retainer
Cost
Other Comments
Consent
I agree with the above treatment and fees for myself or my child
I have been advised that good compliance, wearing appliances as instructed and for as long as directed, is critical for a good outcome
I have been advised of other options, including no treatment or referral to an orthodontist
I have been advised of the risk of treatment which includes but is not limited do. A temporary feeling of having an awkward bite, jaw pain, damage to teeth or roots, discomfort at the begging of treatment
I am to tell the office of any pain in the teeth or jaw as early as possible
I have been advised that oral hygiene is very important throughout treatment and to use an electric toothbrush, interproximal brushes, and water pick. Failure to do so may lead to cavities or discoloration of the teeth that may not be able to be fixed
I have been advised to keep any removable appliance in a box at all times when not wearing it a dn away from any animals
I have been advised that non-compliance may lead to the dentist stopping treatment, and there will be an additional fee to restart.
Addition fees may apply if the appliance needs to be repaired or replaced
Patient or Guardian Signature
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Name
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First Name
Last Name
Date
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Month
-
Day
Year
Date
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