SUBMIT PATIENT REFERRALS ONLINE


PATIENT REFERRAL


REASON FOR REFERRAL

Crowding in upper archPoor rest oral postureVertical growth patternCrowding in lower archDeficient oral volume

Airway signs/symptoms of OSA, including:

TMDSleep Apnea


PERIODONTAL

No periodontal concerns
Previous History of periodontitis, but not currently active


RESTORATIVE & COSMETIC

All pre-orthodontic restorative treatment is complete


REFERRING DOCTOR



PATIENT MOTIVATION

Patient is primarily concerned with:

AestheticsFunctionDiscomfort (TMD)Tooth lossOther

Patient is:

Highly MotivatedIndifferentApprehensive


TMD