OoLi Orthodontics

Treatment Plan - Reviewed & Signed by Orthodontist


Patient Name

 

Patient Number

 

Date of Birth

 

Patient Email

 

Parent/Guardian Name

 

Parent/Guardian Email

 

Patient's Dentist

 

Patient's Dentist

 

Patient's Dentist Email

 

Age

  YO

Race

 

Sex

 

Puberty

 

 At Age

Referred by

 

Last Dental Cleaning

 

Chief Complaint

 

 

 

 

Oral Habits

 

 

Contributory Medical History

 

 

Contributory Dental History

 

 

 

 

 

 

 

Permanent Dentition

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Primary Dentition

A B C D E F G H I J
T S R Q P O N M L K

Angle Classification

 

 Subdivision

Overjet

  mm

 - mm

Overbite Percentage

  %

Anterior Crossbite

 

 

 

Posterior Crossbite

 

 

 

 

 

Maxilla

 

 

Mandible

 

 

Openbite

 

 

 Anterior mm

 Posterior mm

Concerns and Limitations

 

Treatment Option 1

 

 

 

 

Additional Orthodontic Appliance: 

 

 Area of Implant Placement:

 Additional Treatment Information:

Estimated Treatment Time

 

Treatment Option 2

 

 

 

  

Additional Orthodontic Appliance: 

 

 Area of Implant Placement:

 Additional Treatment Information:

Estimated Treatment Time

 

Treatment Option 3

Orthodontic Appliance

 

Estimated Treatment Time

 

Upper Retainer

 

Lower Retainer

 

Leave this empty:

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Signature Certificate
Document name: Treatment Plan - Reviewed & Signed by Orthodontist
lock iconUnique Document ID: aa00acdda49c3ef985d04cbd4f8eca4d59139f1d
Timestamp Audit
September 14, 2020 2:19 pm MSTTreatment Plan - Reviewed & Signed by Orthodontist Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 104.28.111.172
September 15, 2020 1:50 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.182.141.162
September 15, 2020 1:52 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.182.141.162
September 19, 2020 7:15 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.232.157
September 19, 2020 7:21 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.232.157
September 19, 2020 8:06 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.232.157
September 22, 2020 6:18 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.182.141.162
September 22, 2020 6:19 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.182.141.162
September 23, 2020 1:14 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.182.141.162
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May 15, 2021 10:48 am MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 72.222.207.203
December 31, 2021 8:52 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141
December 31, 2021 8:59 pm MSTOoli Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141
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