Dental Clearance for Dental Offices

Thank you for giving us the opportunity to serve you and your patients!

Please fill out the information form below and one of our treatment coordinators will review and facilitate further contact, or help our patient start treatment. You can also call us at 909-774-0107 or e-mail us at Smile @SynergiOrtho.com

Patient Name *

First

Last

Date of Birth *

Dear Doctor, We are thankful for your trust in providing care to our mutual patient, and are excited to make Orthodontics the BEST part of their day! We promise you will not find a team who will work harder to take of this patient. Prior to starting orthodontic treatment, we want to ensure this patient is up to date with their examination/cleanings and does not have any pertinent pending treatment. *

That patient is up to date. No pending treatment.
Dental Work is in progress
Please contact me.

Patient's Last Exam/Cleaning Date *

If their is dental work in progress, please elaborate on which teeth #s, restorative plan, and estimated completion date

Please note anything you are monitoring, or plan to do post-orthodontic treatment.

Anything else we should know?

Practice/Doctor Name *

Practice/Doctor Email *

Practice/Doctor Contact Phone Number

Doctor Signature *

Clear Signature

Date *

We Email the

Custom Captcha *

Schedule your free smile assessment today!