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New Patient Form
Complete the required fields 266
Patient information:
Male
Female
Patient anamnesis:
Case type:
Teeth impression type:
Analog
Digital (STL file)
Arch to treat:
Upper
Lower
Both
Tooth movements restrictions (bridges, ankylosed teeth, implants, etc.):
None (move all teeth)
Teeth...
Dental formula:
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
4.8
4.7
4.6
4.5
4.4
4.3
4.2
4.1
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Patient anamnesis:
Clinical part:
Main complaint:
Crowding
Spacing
Class II div 1
Class II div 2
Class III
Open bite
Anterior crossbite
Posterior crossbite
Deep bite
Narrow arch
Flared teeth
Overjet
Uneven smile
Misshapen teeth
Other
Patient anamnesis:
Clinical part:
Parafunctions:
Bruxism
Infantile type of swallowing
Mouth breathing
Signs of leukoplakia (directly related to pathological occlusion)
Bad habits ( biting something, propping up with one hand, biting lips / cheeks)
TMJ dysfunction:
None
Yes
Deviation of the path of opening the mouth:
Yes
No
Injuries to the maxillofacial area in the past:
Yes
No
Doctor’s prescription:
Anterior-posterior (A-P) relationship:
Maintain current:
R
L
Improve canine relationship only:
R
L
Improve canine and molars relationship:
R
L
Correction to class I:
R
L
Using of elastics:
Yes
No
Using of IPR in the posterior area:
Yes
No
Overjet:
Maintain initial (Overjet may be with use of IPR)
Overjet should NOT be
Overjet should be
Doctor’s prescription:
Overbite:
Maintain initial overbite
Correct open bite
Upper jaw
Intrusion of anterior teeth
Extrusion of posterior teeth
Lower jaw
Intrusion of anterior teeth
Extrusion of posterior teeth
Correct a deep bite
Upper jaw
Intrusion of anterior teeth
Extrusion of posterior teeth
Lower jaw
Intrusion of anterior teeth
Extrusion of posterior teeth
Using the “Bite Stop” system to correct overbite?:
Yes
No
If needed
Doctor’s prescription:
Midline:
Correct if needed
Maintain initial midline (may require IPR)
Improve your midline with IPR
Upper
to patient’s right
to patient’s left
Lower
to patient’s right
to patient’s left
Cross-bite (if present):
Do not correct
Correct
Doctor’s prescription:
Spacing (Tremes / Diastemas):
Close all spaces
Leave spaces
Crowding:
Resolve upper:
Expand:
Primarely
As needed
None
Procline:
Primarely
As needed
None
IPR – Anterior:
Primarely
As needed
None
IPR – Posterior right:
Primarely
As needed
None
IPR – Posterior left:
Primarely
As needed
None
Resolve lower:
Expand:
Primarely
As needed
None
Procline:
Primarely
As needed
None
IPR – Anterior:
Primarely
As needed
None
IPR – Posterior right:
Primarely
As needed
None
IPR – Posterior left:
Primarely
As needed
None
Doctor’s prescription:
Extractions (for orthodontic indications):
None
Extract...
Dental formula:
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
4.8
4.7
4.6
4.5
4.4
4.3
4.2
4.1
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Doctor’s prescription:
Other instructions:
Upload STL files:
Upper
Lower
Occlusion (optional):
Patient photos:
X-RAY images:
Summary:
Patient information:
First name:
Last name:
Phone number:
Gender:
Delivery address:
Patient anamnesis:
Case type:
Teeth impression type:
Arch to treat:
Tooth movements restrictions:
Dental formula:
Clinical part:
Main complaint:
Other complaint:
Parafunctions:
Other parafunctions:
TMJ dysfunction:
Type TMJ dysfunction:
Deviation of the path of opening the mouth:
Injuries to the maxillofacial area in the past:
Doctor’s prescription:
Anterior-posterior (A-P) relationship:
Maintain current:
Improve canine relationship only:
Improve canine and molars relationship:
Correction to class I:
Using of elastics:
Using of IPR in the posterior area:
Overjet:
Overbite:
Upper jaw:
Lower jaw:
Using the “Bite Stop” system to correct overbite?:
Midline:
Upper:
Lower:
Cross-bite (if present):
Spacing (Tremes / Diastemas):
Leave spaces:
Crowding: Resolve upper:
Expand:
Procline:
IPR – Anterior:
IPR – Posterior right:
IPR – Posterior left:
Crowding: Resolve lower:
Expand:
Procline:
IPR – Anterior:
IPR – Posterior right:
IPR – Posterior left:
Extractions (for orthodontic indications):
Dental formula:
Other instructions:
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