duanorthodontics.com-aao_transfer_form

AAO TRANSFER FORM
PATIENT IN ACTIVE TREATMENT
Date

MonthDayYear
To
From
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Email
example@example.com
Patient's name

First NameLast Name
Birth date

MonthDayYear
Sex
Social Security #
Phone Number

Area CodePhone Number
Responsible party
Relationship
Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ANALYSIS (Including significant history & TMD)
PATIENT/PARENT CONCERNS RE: TX
SPECIAL HEALTH OR HISTORY CONCERNS
TREATMENT PLAN (Including chronology of treatment rendered)
TREATMENT PROGRESS (Including chronology of treatment rendered)_
APPLIANCES
Fixed appliance:

Type Manufacturer

1
Type of bracket:

metalnon-metal
Variations

Date bands and/or brackets placed

	Max	Mand	Bonding Agent	Cementing Agent
1

Current archwire size and type:

Max Mand

1
Intraoral elastics: dates initiated, size and direction
Hours requested

Clear tray appliance:

	Manufacturer	Total trays	Trays delivered	Change interval	Case/Patient number
1

PATIENT COOPERATION
Oral hygiene
Headgear
Elastics
Clear trays
Appointments
Broken appliances
Patient's attitude toward treatment
Suggestions for patient motivation
ACTIVE TX TIME ESTIMATES Original
Remaining (% of active treatment completed )
RECOMMENDATIONS FOR CONTINUED TREATMENT
RECOMMENDATIONS FOR RETENTION
ADDITIONAL COMMENTS
FINANCIAL
Closed
Open End (Fixed)
Other
Active Extras

Fees:
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

This patient/parent has been advised that orthodontic treatment fees vary widely throughout the country and the world and it is reasonable for them to expect that a transfer may increase treatment fees and may involve changes in payment policies. For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.

AVAILABLE RECORDS FOR TRANSFER

	Initial	Date	Progress	Date
Casts
Ceph
Tracings
Panoramic
CBCT
Intra-oral scan file
Intraoral x-rays
Facial photos
Intraoral photos

Articulator type

Check appropriate status of records:

	Yes	No
Record duplicates sent upon request (may be an additional charge to patient)
Records enclosed
Records sent under separate cover

Signature (Orthodontist)

Clear
Date

MonthDayYear
I authorize Dr. First Name Last Name to release all records of (patient’s name) for the purpose of continuation of treatment by Dr. First Name Last Name (new provider’s name).
Signature (Patient or Guardian)

Clear
Date

MonthDayYear
Print Name

First NameLast Name
Relationship to Patient
Date

MonthDayYear
Should be Empty: