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 MODmouth to ensure the best Orthodontic outcome for our patient. Please do not hesitate to contact MODmouth with any questions or concerns.
Address: 1714 East 23rd Street, Brooklyn, NY 11229