Periodontal Clearance for Orthodontic Treatment
Patient Name
*
First Name
Last Name
Date of most recent periodontal or hygiene visit:
*
3 months
3-6 months
Over 6 months
Other
Periodontal Status
*
Please Select
Patient has no active periodontal disease
Patient has a history of periodontal disease but is currently stable
Patient has active periodontal disease requiring treatment or stabilization
Clearance for Orthodontic Treatment
*
Please Select
Cleared for orthodontic treatment at this time
NOT cleared for orthodontic treatment at this time
Areas of Concern (if any):
*
None
Yes-Please specify:
Ongoing Periodontal Care
Please Select
Patient is under routine periodontal maintenance
Periodontal treatment is recommended prior to or during orthodontics
Additional Comments:
Treating Dentist:
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
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