Download General Dentist Clearance Form - Dayton Dental and Orthodontics

Dayton Dental and Orthodontics
2727 Fairfield Commons Blvd.
Dayton, OH 45431
P: 937-431-0947
F: 937-431-0950
8340 Yankee St.
Centerville, OH 45458
P: 937-433-1494
F: 937-433-7763
To primary general dentist,
To start orthodontic treatment on the patient, we now require this form be filled out by the
patient’s primary general dentist. This is to make sure the patient’s oral health meets the standards
required to start orthodontic treatment. Please complete the area below and return this letter to us as
soon as possible preferably by fax to the above listed fax number of the office the patient is scheduled at
or you can email to [email protected] or mail to the above corresponding address. If you are
unable to check all statements listed below to clear patient for orthodontic treatment, than we cannot
start treatment on this patient. Patient will need to be up to date on general dentistry treatment before
able to start orthodontic treatment. Please call with any questions to above listed number of the
corresponding office.
Patient:
DOB:
Date of last dental exam:
Please check all that apply:
__Patient has received an oral examination and was found to be free of untreated oral disease or other
conditions that may make orthodontic treatment unsuccessful or harmful.
__The patient demonstrates oral hygiene habits consistent with being able to prevent inflammation and
dental decay during orthodontic treatment.
__Sealants are in place on all of the patient’s unrestored erupted permanent molars if applicable.
__The patient has all needed dental treatment completed and is able to start orthodontic treatment.
If unable to check off all statements listed above, please list any conditions that patient still needs
treated:
Dentist name (please print):
Dentist signature:
Date: