Orthodontic Exam & Agreement & Treatment plan Orthodontic Exam & Agreement & Treatment planPatient's Name *File NumberProfile:StraightConcaveConvexFace:NormalLongShortDentition:PrimaryEarly mixedLate mixedPermanentDental Classification:Right molarLeft molarRight canineLeft canineChoose ClassClass IClass IIClass IIICephalometric Analysis:SNASNBANB Result (skeletal classification)Other FactorsDiastemaMissing /extracted toothSupernumerary toothImpacted toothMalformed toothHabitsFigure /Thumb SuckingTongue thrust /SwallowThick frenumOver jet:NormalIncreasedDecreasedCrossbitemmOverbite:NormalIncreasedOpen biteClosed bitemmPosterior Crossbite (Functional)UnilateralBilateral2 TeethShiftingTowards RightTowards LeftCrowding/SpacingMild (1-2MM)Moderate (3-4MM)Sever (<5 MM)TMJ SymptomsClickingCrepitusNormalTreatment plan12345Note: the treatment plan could be altered by the dentistCost of treatment:Orthodontic recordCADFee of braces installmentCADMonthly paymentCADTotal feeCADSignee Role: (Please check one) *PatientParent / Guardian (if minor)Signee Name *Date *Signature *Sign hereYour browser does not support e-Signature field.Submit
