New Patient
General Information
Doctor's Name
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Patient's Name
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Phone
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Age
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City
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Street Address
Street Address Line 2
State / Province
Postal / Zip Code
Gender
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Male
Female
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Email
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example@example.com
Patient type
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Local
Overseas
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Chief Complaint
Medical and Dental History
Illness
Medications
CHEMO / RADIOGRAPHY
STEROIDS / BISPHOSPHONATES
GINGIVITIS
RESESSION
MOBILITY
BONE LESS
TMJ ISSUES
Dental Prosthesis/Restoration
Restoration Notes
Impacted/Missing/Ankylosed/Deciduous Teeth
Impacted Notes
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Dental Examination
Treatment Indicated
Both
Upper
Lower
Teeth to be moved
Upper
Lower
3 to 3
5 TO 5
7 to 7
Teeth to be moved
Upper
Lower
3 to 3
5 TO 5
7 to 7
Incisor Relationship
Overjet
Overbite
Cross Bite
Skeletal
Dental
Black Triangles
Present
Absent
Teeth to not be moved
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Adviced TX
Space Clouser
Complete
Leave Space
Upper Arch
Lower Arch
Crowding Resolution
IPR
PROCLINATION
Expansion
Extraction
Midline
Maintain
Correct
Move Upper
Move Lower
Permanent Canine Occlusion Goal
R
L
Class I
Class II
Class III
Permanent Molar Occlusion Goal
R
L
Class I
Class II
Class III
Incisor Relationship
Overjet
Overbite
CORRECTION OF DENTAL CROSS BITE
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