Patient Name
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Date of Birth
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Phone
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Email
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Referred By
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Treatment Needed
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Orthodontics
Periodontics
Pediatric Dentistry
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Reason(s) For Referral (Ortho)
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Early Eruption Guidance
Crowding
Spacing
Overjet
Overbite
Crossbite
Open Bite
Narrow Dental Arches
Impacted Teeth
Missing Teeth
Protruding Teeth
Oral Habits
TMJ Disorder
Sleep Disorder
Reason(s) For Referral (Perio)
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Emergency Care
Restorative Care
Oral Examination
Dental Hygiene Services
Caries / Decay
Chipped, Broken Teeth
Night Guard / Sports Guard
Nitrous Oxide
Space Maintainer
Take a Panoramic X-Ray
Frenectomy
Crowns
Sedation
Extraction
Sealants
Reason(s) For Referral (Pediatric)
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Comprehensive Perio Exam
Limited Perio Exam
Gingival Recession / Grafting
Crown Lengthening
Implant Therapy or Repair
Extraction Tooth Exposure
Biopsy / Oral Lesion
Notes
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