Download crs orthodontia treatment plan

CRS ORTHODONTIA TREATMENT PLAN
Children’s Rehabilitative Services Program @ St. Joseph’s Hospital and Medical Center
124 W. Thomas Road, Phoenix, AZ 85013
Patient
Name:
MR#:
Date:
602-406-6400
Requesting Dentist:
Oral Surgeon:
Plastic Surgeon:
Type of Submission: (circle one) Is this the 1st Orthodontia Treatment Plan or a continuation/extension of care?
Diagnoses:
Treatment Outline: (Layman terms)
Treatment start date:
Proposed length of this phase of treatment in months:
Are additional phases of treatment anticipated: Y/N
At what age will this second phase of treatment begin:
Is alveolar bone graft needed? Y/N
At what age?
Is dental extraction needed?
Y/N
At what age?
Is oral surgery anticipated:
Y/N
At what age?
Is orthognathic surgery anticipated: Y/N At what age?
Are prosthetic services indicated:
GENERAL DESTISTRY & HYGIENE VISITS MUST BE SET FOR A MINIMUM OF EVERY 6 MONTHS. (Bands
may need to be removed for restorations)
Dictation on each case must be made for the CRS medical record quarterly. This informs all the
members of the Craniofacial team how the patient is progressing. Please dictate so that all team
members can understand the treatment plan. Remember to cc: the CRS dental clinic or the private
orthodontia office for shadow records/notes.
To dictate into the hospital system, call 602-406-7788: Dental license #, 31#, MR#, and then press 2
to dictate.
Medical Director Notes:
Medical Director Signature:
10/04
Date:
CRS Orthodontia
Approved: __________
Denied:______________