Peak Smiles HQ - Clinical Information Form

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Peak Smiles CLINICAL INFORMATION FORM for Invisalign Treatment

Please complete the form below.

CUSTOMER INFORMATION

CLINICAL INFORMATION

Occlusion & Midlines

Overbite, Overjet & Crossbites

Crowding & Spacing

Splinted Teeth

I flossed between all teeth and noted the following:

Notes from flossing:

Teeth that may/should not be moved during Orthodontic Treatment

FIXED BRIDGES-Retainers-(Pontics)

IMPLANT-RETAINED TEETH

RETAINED PRIMARY TEETH

MOBILITY & POOR PROGNOSIS TEETH

IMPACTED TEETH (if unsure - ie 1.8?)

MISSING TEETH

OTHER SPECIAL PATIENT NOTES and/or DENTIST REQUESTS

Please submit the Clinical Information Form below

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