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Patient:______________________________ Age:______years ______months Date:_____________ WELCOME TO OUR OFFICE! From the initial examination that has just been completed, the Doctor has the following concerns: _____Overbite (overjet) _____Back teeth not lined up _____Jaw relationship problem: _____ Underbite _____ Lower jaw underdeveloped _____ Upper jaw underdeveloped _____Expected jaw growth limited or unfavorable direction _____Crossbite _____Arch constriction or narrow arch form _____Midline shift _____Dental asymmetry _____Excessive gum showing with smiling _____Openbite _____Tongue thrust _____Excessively deep bite _____ Wear of teeth _____Crowding of the teeth _____Spacing of the teeth _____Rotations of the teeth or malalignment _____High root resorption potential _____Missing teeth _____Oral hygiene concerns _____Gum concerns: _____gingivitis _____frenum _____recession potential _____TMJ signs or symptoms or history of problems___________________________________ _______________________________________________________________________ _____Other____________________________________________________________________ The Doctor has suggested the following: _____ Reevaluation/Recall in 6 months to check development _____ Phase I - Early Treatment which may consist of: _____ Limited braces _____ Jaw alignment/Growth appliance _____ Expansion _____ Extraction of primary teeth _____ Other_____________________________________________________________ The anticipated length of this treatment would be _______ months and the cost would be approximately $__________ to $__________ which can be paid with an initial fee and the balance spread out over the treatment period. Other financial arrangements can also be set up. Phase II treatment may follow Phase I treatment. _____Phase II - Full Orthodontic Treatment _____ Full braces _____ Jaw alignment/Growth appliance _____ Expansion _____ Extraction of teeth _____ Bite buttons _____ Elastics _____ Other______________________________________________________ The anticipated length of this treatment would be ________ months and the cost would be approximately $____________ to $____________ which is usually paid with an initial fee and the balance spread over the treatment period. Other financial arrangements can also be set up. This treatment fee includes debanding, final records, one set of retainers and the cost of retention supervision for two years.
