Up Valley Orthodontics Referral
Board Certified Orthodontist
Specialist in Braces and Invisalign for Children & Adults
Patient
Date
Referring Doctor
Please call patient to schedule an appointment
Yes
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Patient will call to schedule an appointment
Yes
AREAS OF CONCERN
Crowding
Crossbite
Spacing
Impacted Tooth
Overjet
Space Maintenance
Overbite/Underbite
Other
RESTORATIVE TREATMENT
is complicated
is underway
is pending outcome of orthodontic finding
Comments
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