Aao transfer form patient in active treatment



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AAO TRANSFER FORM
PATIENT IN ACTIVE TREATMENT


Date      

To      

From      

Phone (     )      -      Fax (     )      -     
Patient's name       Birth date       Age       Sex      

Social Security #     -    -      Phone (     )      -     

Responsible party       Relationship:      

Home address       City       State/Province       Zip code      




ANALYSIS (Including significant history & TMD)      
PATIENT/PARENT CONCERNS RE: TX      
SPECIAL HEALTH OR HISTORY CONCERNS      
TREATMENT PLAN (Including chronology of treatment rendered)      

APPLIANCES

Appliance (type, manufacturer, type of bracket–metal or non metal, and variations)      

Date bands and/or brackets placed: Max       Mand       Bonding Agent       Cementing Agent      

Current archwire size and type: Max       Mand      

Extraoral type and dates initiated       Hours requested      

Intraoral elastics, dates initiated, size and direction       Hours requested      

Removable appliance type and dates initiated       Hours requested      
PATIENT COOPERATION

Oral hygiene       Headgear       Elastics      

Appointments       Broken appliances      

Patient's attitude toward treatment      

Suggestions for patient motivation      
ACTIVE TX TIME ESTIMATES Original       Remaining       % of active treatment completed      


ACTIVE TREATMENT RECOMMENDATIONS      
RETENTION AND THIRD MOLAR RECOMMENDATIONS      
ADDITIONAL COMMENTS      
FINANCIAL

Closed       Open End (Fixed)       Other      

Fees: Active       Extras      

Terms      

Third party payment      

Total charges before transfer      

Total amount paid before transfer      

Unpaid amount still owed transferring office      

Balance of original quoted fee not yet charged       or overpaid at transfer      

TRANSFER OF RECORDS (Enter date)      

Dates of our: Records      

Casts       Articulator type      

Cephalograms       Tracings      

Intraoral radiographs      

Facial photographs      

Intraoral photographs      

Transferring Duplicate  Initial 

Original  Progress 

Check appropriate status of records

Record duplicates available upon request at extra charge Yes No

Records enclosed Yes No

Under separate cover Yes No

Signature: __________________________________________________Date_______________________

(Orthodontist)





PATIENT RECORDS RELEASE AUTHORIZATION
When a patient moves, or, for other reasons, there is a necessity to change orthodontists during the course of ongoing orthodontic treatment, it is highly advantageous for all involved parties that the transfer be as prompt and convenient as possible. Of paramount importance is the identification of an orthodontist who will accept the patient and successfully complete the treatment.
The American Association of Orthodontists represents over ninety percent of the orthodontic specialists in the U.S. and Canada. Your current doctor is a member and will assist you in finding a qualified orthodontist.
It is necessary that your records be transferred to assure that the receiving orthodontist is knowledgeable of your orthodontic condition(s), orthodontic treatment goals, the current treatment plan, and related financial arrangements. To facilitate the transfer of these records, it is necessary that you complete the following:
I authorize ___________________________________________ to release all records of

(Orthodontist's Name)


__________________________________ for the purpose of continuation of treatment by another orthodontist.

(Patient's Name)


Signature: __________________________________________________________Date_______________________

(Patient or Guardian)


Print Name ________________________________________
Relationship to Patient _______________________________


© American Association of Orthodontists 1999

Transfer – Active 5/00

Reviewed 09/09




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