www.ampsmiles.com- Clearance for Orthodontic Treatment

Clearance for Orthodontic Treatment

Please complete this form to confirm whether our mutual patient is ready to begin orthodontic treatment at Amp Orthodontics & Kids Dental.
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Referring Provider Information
Dentist Name
Practice Name
Email*
example@example.com
Date of Patient’s most recent visit

MonthDayYear
Date
Restorative Clearance

(Required to check one box)
Patient is cleared to begin orthodontic treatment. All restorative needs have been addressed.Patient requires restorative treatment prior to commencing orthodontic care.
Please provide additional information (if applicable)
Please provide details of required treatment:
Periodontal Clearance

(Required to check one box)
No periodontal concerns noted.The patient has a history of periodontal disease, but is currently stable and under regular maintenance.Patient has Periodontal concerns that require further attention prior to starting orthodontic treatment.
Please provide details of required treatment and upload perio chart below.
Additional Notes (Optional)
Upload recent radiographs or clinical documentation

Cancelof
HIPAA NOTICE

This form is intended for the secure transmission of clinical information. Please ensure all shared documents comply with HIPAA and patient privacy standards. If you have any questions, contact our office directly at 336-999-0123.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Clearance for Orthodontic Treatment