417-206-7770
Date:
Referring Doctor:
Patient's Name:
Patient's Phone Number:
Patient's Age:
Guardian's Name/Relation:
Please evaluate for:
Crowding
Growth (overbite, underbite, etc.)
Crossbite (anterior, posterior)
Habits (thumb sucking, tongue thrust, etc.)
Mixed dentition concerns (narrow palate, space maintenance, growth pattern, etc.)
Pre-prosthetic considerations (abutment preparation, rotations, tipped molars, over-eruption, etc.)
TMD considerations (pain, noises, CR/CO discrepancy, etc.)
Comments:
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Dr. Michael R. LaFerla, Orthodontist | 2805 E 29th St, Joplin, MO 64804 | 417-206-7770
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