Doctor's Name* Doctor's Phone Number* Doctor's Email* Practice Name* Practice Address*
Patient's Name* Patient's Phone Number* Patient's Email*
OrthodonticsEndodonticsProsthodonticsOral Surgery
General orthodontic care Arch crowding/spacingOpen biteDeep biteOverjetImpacted teethCrossbite
Early interceptive care Facial growth disorderHabit correctionsSpace maintenanceDentofacial orthopaedicsEctopic eruptionFunctional shift
Advanced orthodontic care Orthodontic surgical careDentofacial imbalancePre-prosthetic alignmentImplant site developmentMissing teethInvisalign/ lingual orthodontics
ImplantCrownBridgeVeneersDenturesTMDTooth surface lossOcclusal vertical dimensionFull-mouth rehabilitation
AestheticFunctionalHygienicPrognosis without intervention
SingleSegmentalComplete
Interim diagnosisDefinitive diagnosisInterim procedures
Full referralCo-manageDecision-support
Consultation/DiagnosisEndodontic treatmentRe-treatmentPerforationNon-vital bleachingApical surgeryFractured instrumentPost removalDental traumaRoot resorption
Post space preparationPlacement of the core
ConsultationTooth removalWisdom teethPathologyTooth exposureDental implant placementOther
OPGBW/PACT/CBCTNone
Are being emailedAre with the patient
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