Download (Adult)- General Dentist Clearance Form

Dayton Dental and Orthodontics
8340 Yankee St.
Centerville, Oh 45458
P: 937-433-1494
F: 937-433-7763
2727Fairfield Commons Blvd.
Dayton, OH 45431
P: 937-431-0947
F: 937-431-7763
To primary general dentist,
To start orthodontic treatment on the patient, we now require this form to be
completed 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 all general dentistry treatment before able to start
orthodontic treatment. Please call with any questions.
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.
The patient does not have any active periodontal disease.
The patient has all needed dental treatment completed and is able to start orthodontic
treatment.
If unable to check off all statement listed above, please list any conditions that patient still
needs treated:
Dentist name (please print):
Dentist Signature:
Date: