Orthodontic Exam & Agreement & Treatment plan

Patient's Name *

File Number

Profile:StraightConcaveConvex

Face:NormalLongShort

Dentition:PrimaryEarly mixedLate mixedPermanent

Dental Classification:Right molar

Choose ClassClass IClass IIClass III

Left molar

Class IClass IIClass III

Right canine

Class IClass IIClass III

Left canine

Class IClass IIClass III

Cephalometric Analysis:SNASNBANB Result (skeletal classification)

Other FactorsDiastemaMissing /extracted toothSupernumerary toothImpacted toothMalformed toothHabitsFigure /Thumb SuckingTongue thrust /SwallowThick frenum

Over jet:NormalIncreasedDecreasedCrossbite

mm

Overbite:NormalIncreasedOpen biteClosed bite

mm

Posterior Crossbite (Functional)UnilateralBilateral2 Teeth

ShiftingTowards RightTowards Left

Crowding/SpacingMild (1-2MM)Moderate (3-4MM)Sever (<5 MM)

TMJ SymptomsClickingCrepitusNormal

Treatment plan

1

2

3

4

5

Note: the treatment plan could be altered by the dentist

Length of treatment:

Months

Cost of treatment:

Orthodontic record

CAD

Fee of braces installment

CAD

Monthly payment

CAD

Total fee

CAD

Signee Role: (Please check one) *PatientParent / Guardian (if minor)

Signee Name *

Date *

Signature *

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