MOD Mouth Dental Clearance Form

First Name:
Last Name:
DOB

To primary general dentist,

To start orthodontic treatment on the above patient, we request this form be filled out by the patient’s primary general dentist. This is to make sure the patient’s oral health meets the standards required to start orthodontic treatment. Please complete the area below and then fax, email, or mail along with any X-rays (PA’s, bitwings, or Panoramic) that you would like to share with the dentists at MOD Mouth to ensure the best Orthodontic outcome for our patient. Please do not hesitate to contact MOD Mouth with any questions or concerns.

MOD Mouth,
Address: 1714 East 23rd Street, Brooklyn, NY 11229
Phone: 1-844-MODMOUTH
Email: info@mod-mouth.com

Date of last dental exam:
Please check all that apply:
Patient has no active caries or restorations that need to be replaced. Patient has no active periodontal disease and has no excessive mobility on any teeth (class II or greater) Patient has no impacted, over retained primary teeth, or supernumerary teeth Patient has no evidence of short roots or root resorption Patient has no evidence of TMD (Temporomandibular joint disorder)
If unable to check off all statements listed above, please list any conditions that patient still needs treated:
Dentist name (please print):
Date:
Signature:

Clear

© 2018 MOD Mouth, Inc Privacy Policy | Terms & Conditions