Quick Exam Checklist

This checklist is for your records only. It is not a referral form. The details will be sent to your email address so it can be copied into your management software (i.e. D4W, Oasis). No information is stored on our servers.

ᵅ early referral/treatment indicated (between 6-11 years old)
ᵝ comprehensive referral/treatment indicated (12+ years old)
See Summary table (link will open in new tab) for a simple reference.

Patient identifiers are limited on this form so patient privacy is maintained.
Enter the incisor midline relative to the facial midline
Selected Value: 0
Reduced overjet ( ≺1mm ) ᵅᵝ | Excess overjet ( ≻3.5mm ) ᵅᵝ
List any additional details to the above findings or any findings not covered.
Your email is used to send the exam information to you. Your email is confidential and not used for any marketing or promotional purposes.