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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

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

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

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Timestamp

Audit

September 14, 2020 2:19 pm MST

Treatment Plan - Reviewed & Signed by Orthodontist Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 104.28.111.172

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