Dental Aligner Treatment Assessment Form
Assess your alignment concerns, oral health factors, and treatment readiness for clear aligner planning.
Patient and Treatment Basics
Patient Full Name
*
First Name
Middle Name
Last Name
Age or Age Range
*
Primary Reason for Seeking Aligner Treatment
*
Alignment Concern Level
*
Minor
Moderate
Major
Oral Health and Alignment Assessment
Alignment Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Primary Bite Concern
*
Crowding
Spacing
Overbite
Underbite
Crossbite
Other
Prior Orthodontic Treatment
*
Yes
No
Do you currently have retainers, crowns, bridges, implants, or missing teeth that may affect treatment planning?
*
Yes
No
Treatment Readiness and Logistics
Preferred treatment start timeframe
*
As soon as possible
Within 1 month
Within 1–3 months
Within 3–6 months
Not sure yet
Current dental work or upcoming procedures before treatment
Submit Assessment
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