Download Dr. David J. Rudolph DDS, MS, Ph.D. Practice Limited to Orthodontics

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Dr. David J. Rudolph D.D.S., M.S., Ph.D. Practice Limited to Orthodontics
9453 Gierson Ave. Chatsworth, CA 91311 · Tel: (818) 718-1737 Fax: (818) 718-1735
Patient Name: _______________________________
Date: ________________
We greatly appreciate the opportunity to provide excellent Orthodontic therapy to our mutual patient.
Great orthodontic can be achieved with regular teeth cleanings (at least once every three months) and
regular dental exams.
In order for us to make sure our mutual patient follows-up with dental care at your office please complete
the necessary procedure and return this form to the patient to give to our office.
Please evaluate the patient for the following:
Periodontal and Oral Hygiene:
1) Prophy / Teeth Cleaning
2) Scaling
3) Deep Cleaning
4) Periodontal Therapy
5) Oral Hygiene Instructions
6) Other ________________________
Dental Exam:
7) Caries Check
8) Oral Cancer Exam
9) Bleaching
10) Veneers / Esthetic Dentistry
11) Radiographs
12) Extraction _________________________________________
13) Expose and Bond _________________
14) Implant/Bridge/ Tooth Replacement ____________________
15) Other ________________________