Inter-Company Patient Transfer Form
Transfer Information
Date
*
-
Month
-
Day
Year
Date
Transferring From Clinic:
From Clinic Name
*
Please Select
Smilz - Calgary Sunridge Mall
Spruce Grove
Align - Sherwood Park
Align - Hewes
Align - TMD
Campbell River
Comox
Williams Lake
Victoria
Cranbrook
Ocean
North Delta
Squamish
Whitehorse
Winnipeg - Portage La Prairie
Winnipeg - St Vital
Thompson
Le Pas
Brandon
Fredericton
Grand Falls
Woodstock
Charlottetown
Summerside
Sydney
Truro
Metro
Bedford
London
Simcoe
Ottawa
Sudbury
Timmins
Toronto - Bloor
Milton
Markham
Oshawa
Scarborough
Stouffville
Thornhill
Keswick
Ancaster
Sarnia
Waterloo
North York
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Origininating Clinic Email
*
Transferring From Doctor information
Transferring From Doctor Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor Email
Receiving Clinic:
Receiving Clinic Name
*
Please Select
Smilz - Calgary Sunridge Mall
Spruce Grove
Align - Sherwood Park
Align - Hewes
Align - TMD
Campbell River
Comox
Williams Lake
Victoria
Cranbrook
Ocean
North Delta
Squamish
Whitehorse
Winnipeg - Portage La Prairie
Winnipeg - St Vital
Thompson
Le Pas
Brandon
Dieppe
Fredericton
Grand Falls
Moncton
Woodstock
Charlottetown
Summerside
Bridgewater
Dartmouth
Halifax
Sydney
Truro
Yarmouth
Metro
Bedford
London
St. Thomas
Kitchener
St Catharines
Brantford
Simcoe
Ottawa
Sudbury
Timmins
Toronto-Midtown
Toronto - Bloor
Milton
Markham
Oshawa
Scarborough
Stouffville
Toronto
Thornhill
Keswick
Ancaster
Sarnia
Waterloo
North York
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Receiving Clinic Email
example@example.com
Patient Information
Patient First Name
*
Patient Last Name
*
Patient Common Name (if any)
Date of Birth
*
-
Month
-
Day
Year
Date
Responsible Party
*
First Name
Last Name
Relationship to Patient
*
Chart ID
New Home Address (if available)
Street
City
Postal Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Back
Next Section
Transfer Records
Records being forwarded include
*
Models
Ceph
Tracings
Panorex
Photos
Other
Case Information
Case Analysis
Treatment Plan
Patient Start Date
*
-
Month
-
Day
Year
Date
Original estimated tx time
*
Back
Next Section
Estimated time remaining
*
Appliances - i.e. type of brackets
*
Bracket Slot Sizes
*
Date Bands and/or brackets cemented if different than start date
-
Month
-
Day
Year
Date
Current upper archwire size
Current lower archwire size
Headgear type:
Headgear hours requested:
Intraoral elastics - force direction and size
Intraoral elastics - hours requested
Removable appliances type:
Removable appliances hours requested:
If Invisalign Treatment
Aligner status
Patient has all aligners
Aligners have been forwarded to the new clinic
Total Aligners ordered
Patient currently wearing upper aligner number:
Patient currently wearing lower aligner number:
Patient Cooperation
Oral hygiene
Good
Poor
Appl/Aligner wear
Good
Poor
Elastic Wear
Good
Poor
Appt Attendance
Good
Poor
Patient Contract
Estimated Fee
*
How were fees arranged
*
Total amount paid before transfer:
*
Unpaid amount owing
*
Lifetime retention program paid
*
Yes
No
Back
Next
Documents
Records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
FC Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Invisalign Documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient Info (Tx history, consent, reports, Tx plan/notes, letters)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: