Home Provider Treatment Instructions

To be completed by the patient's primary treating orthodontist/dentist. Your instructions guide the limited emergency care provided at our office. Fax to (305) 786-5028 or email dreljach@cocosmilesorthodontics.com prior to (or at the time of) the patient's visit.

1. Patient Information

Patient Name

Date of Birth

Anticipated Visit Date

2. Home Provider Information

Provider Name (Dr.)

Practice Name

City / State

License # / State

Phone

3. Current Treatment Status

Current Wire / Aligner Stage

Treatment Stage

Next Appt with Home Office

4. Teeth Involved — Universal Numbering System

Circle or mark the involved teeth directly on the chart (finger or mouse).

Teeth Involved (Universal #s)

Presenting Problem

5. Instructions to COCO Smiles Orthodontics

Specify exactly what you authorize and how you would like the emergency addressed (e.g., "clip distal wire only — do not adjust," "re-bond bracket #8 in current position, do not re-ligate elsewhere," "do not change wire sequence"). Include anything we should avoid.

Home Provider Signature — sign below with finger or mouse

Sign here

Printed Name

Credentials (DDS/DMD/MS)

Date

Emergency Palliative Visit — Provider Authorization Form

1. Patient Information

2. Home Provider Information

3. Current Treatment Status

4. Teeth Involved — Universal Numbering System

5. Instructions to COCO Smiles Orthodontics