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Name
DOB
Age
Parent Name
Phone
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Date Referred
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Referring Dr.
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what needs to be done prior to starting treatment?
Referral Concerns for Orthodontic Treatment
Impaction of Tooth
Crossbite/Functional Shift
Missing Teeth
Growth/Skeletal Imbalance
Openbite
Speech Disorder
Other
Crowding
Overbite
Overjet
Space Maintenance
Spacing
Oral Habit/Tongue Thrust
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