Orthodontic Treatment Progress Form
Please fill out this form to document the patient's orthodontic treatment progress and observations at each visit.
Patient Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Email Address
example@example.com
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Treatment Phase
*
Please Select
Initial Evaluation
Alignment and Leveling
Space Closure
Finishing and Detailing
Retention
Other
Oral Hygiene Assessment
*
1
2
3
4
5
Type of Orthodontic Appliance Used
*
Please Select
Braces (Metal)
Braces (Ceramic)
Clear Aligners
Retainers
Other
Observations and Clinical Findings
*
Any Issues or Complications Encountered?
Broken Bracket
Loose Wire
Lost Aligner/Retainer
Gum Irritation
Other
Planned Adjustments/Next Steps
*
Orthodontist's Notes
Orthodontist/Provider Signature
*
Submit Progress
Submit Progress
Should be Empty: