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PATIENT REFERRALS
Doctor's Name
Doctor's Email
Patient's Name
Patient's Telephone
Patient's Age
Patient's Email
Evaluation particuarly noting the following problems:
Jaw size/growth discrepancy (Class II, III, asymmetry)
Open bite or deep bite
Crossbite (anterior, posterior, narrow palate)
Pre-prosthetic considerations
Invisalign consult
Functional or developmental anomolies (cleft lip/palate, breathing/swallowing or speech problems)
Other
Radiographs:
Full mouth series
Bitewing
Panoramic
Thank you for your referral!
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