WP E-Signature by Approve Me - Sign Documents Using WordPress -

Orthodontic Progress Report

Signed Date

Date

Patient Name

Date of Birth

Patient Email

Parent/Guardian Name

Parent/Guardian Email

Patient's Dentist

Patient's Dentist's Email

Start of your orthodontic treatment

Estimate length of your orthodontic treatment

Duration of your orthodontic treatment to date

Angle Clarification

Overjet (mm)

Overbite Percentage

How is your orthodontic treatment progressing?

Why is your orthodontic treatment progress poor?

What needs to improve?

How is your brushing/oral hygiene?

Estimate of time remaining before completion of your orthodontic treatment

How Much Do You Like Your Smile

Estimate length of your orthodontic treatment

This referral was sent to your dentist

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

January 13, 2022 2:05 pm MST

Orthodontic Progress Report Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 104.28.111.172

May 11, 2024 9:30 pm MST

OoLi Team - forms@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 68.104.180.82

May 12, 2024 7:42 am MST

OoLi Team - forms@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 68.104.180.82

August 14, 2025 12:20 pm MST

OoLi Team - forms@ooliortho.com added by Won-Woo Jonathan Park - forms@ooliortho.com as a CC'd Recipient Ip: 104.28.111.172