Pediatric Clear Aligner Evaluation
Please complete this form to help us assess your child’s suitability for clear aligner orthodontic treatment.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Reason for Evaluation
*
Has your child had previous orthodontic treatment?
*
Yes
No
Oral Hygiene Habits
Brushes twice daily
Uses dental floss
Uses mouthwash
Supervised brushing
Other
Does your child have any of the following oral habits?
Thumb/finger sucking
Mouth breathing
Teeth grinding
Nail biting
Other
Current Dental Concerns (select all that apply)
*
Crowding
Spacing
Overbite
Underbite
Crossbite
Open bite
Other
Clinical Observations
*
Rows
Normal
Mild Issue
Moderate Issue
Severe Issue
Overjet
1
2
3
4
Overbite
5
6
7
8
Crossbite
9
10
11
12
Crowding
13
14
15
16
Spacing
17
18
19
20
Relevant Medical History (allergies, ongoing medications, medical conditions)
Parent/Guardian Signature
*
Submit Evaluation
Submit Evaluation
Should be Empty: