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Peak Smiles CLINICAL INFORMATION FORM for Invisalign Treatment

Please complete the form below.

CUSTOMER INFORMATION

CLINICAL INFORMATION

Missing Teeth #'s - Include Ct Comments

Missing Teeth Options

Splinted Teeth

Flossing - give ct a flosser and then ask: "Are you able to floss between each and every tooth?"

Teeth that may/should not be moved during Orthodontic Treatment

Midline

Overbite, Overjet & Crossbites

Crowding & Spacing

OTHER DENTISTRY DISCUSSED:

Other future/potential dentistry discussed

OS Pro NOTES:

OS Pro Simulation
Black Triangles & IPR discussions (Additional Fee) Required

OTHER SPECIAL NOTES:

Please submit the Clinical Information Form below

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