Orthodontic Treatment Request

✓ Submitted!

Referring Orthodontist

Orthodontist Name *

Practice Name *

Office Phone *

Office Email

Patient Information

Patient Name *

Date of Birth *

Parent / Guardian Name *

Parent Phone *

Treatment Requested

Select all procedures needed:

Serial Extractions

Specific Tooth Extractions

Surgical Exposure of Impacted Tooth

Space Maintainer Placement

Frenectomy

Supernumerary Tooth Removal

Gingivectomy / Soft Tissue

Other (specify below)

Tooth Numbers *

Sedation Preference

Urgency

Preferred Location

Additional Information

Medical Conditions / Allergies

Special Instructions

Submitted By *

Date