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CONFIDENTIAL HEALTH INFO
First Name
Middle Initial
Last Name
Nickname
Birthdate
Address
Address
Main Phone
Evaluation particuarly noting the following problems:
Jaw size/growth discrepncy (Class II, III, asymmetry)
Open bite or Deep Bite
Crossbite (anterior, posterior, narrow palate)
Pre-prosthtic considerations
Invisalign consult
Functional or developmental anomolies (Cleft Lip/Palate, breathing/swallowing or speech problems)
Radiographs:
Full mouth series
Bitewing
Panoramic
Thank you for your referral!
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