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Smile Plan

The document outlines a patient plan for addressing malocclusion and improving smile aesthetics through a structured consultation process. It includes sections for patient details, concerns, treatment preferences, and clinician assessments related to dental issues. The document also emphasizes the importance of privacy regarding personal data and introduces Invisalign as a potential treatment option.

Uploaded by

Anuradha Rajkuwar
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6 views2 pages

Smile Plan

The document outlines a patient plan for addressing malocclusion and improving smile aesthetics through a structured consultation process. It includes sections for patient details, concerns, treatment preferences, and clinician assessments related to dental issues. The document also emphasizes the importance of privacy regarding personal data and introduces Invisalign as a potential treatment option.

Uploaded by

Anuradha Rajkuwar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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My Smile Plan.

Straight teeth, the foundation of a healthy, beautiful smile.


Your smile concerns are our concerns too. By tackling your malocclusion concerns now, we can help you to
prevent potential health consequences and associated expenses from occurring in the future and help you to
achieve the smile you desire.

Step 1:

Patient details.

Name: DOB:

Phone: Email:

My concerns with my teeth are. (Please tick the relevant boxes below)

Food traps between my teeth during eating Spaces between my teeth/missing teeth

Pain in my teeth, jaw, head or neck A narrow smile

Lisp when I speak Large black gaps at the corners of my mouth

Crooked or overlapping teeth Symmetry of my teeth

The way my teeth look in photographs I grind my teeth

The way my teeth look from the side

Do you have an important life event coming up that you would like to prepare your smile for?

Yes No

If yes, tell us what and when:

What changes would you make to improve your smile? Straight teeth Whiter teeth Replace broken/missing teeth

Have you had Orthodontic (teeth straightening) treatment in the past? Yes No

Would you like to have treatment to improve your smile? Yes No

How soon would you like to start treatment to improve your smile?

Immediately 1-3 months 3-6 months 6-12 months


CLINICIAN TO FILL

Step 2:

Clinician consultation.

Date of appointment: Date of appointment:

Follow up Consultation ClinCheck® review

Patient’s teeth issues related to malocclusion. (Please tick the relevant boxes below)

Teeth are shifting/crowding Bite alignment

Teeth are missing Wear from grinding

Teeth are protruding Arch Asymmetry

Identified teeth issues related Wear from grinding


to the patient’s malocclusion

Gum disease exacerbated Teeth are chipping


by malocclusion or grinding

Midline shift Enamel is thinning

Potential health consequences discussed with patient. (Please tick the relevant boxes below)

Tooth decay and/or tooth loss Premature wearing of teeth


Gum disease, and/or tooth loss Trauma to front teeth
(e.g. chipping, cracking)

Recommended solution.

The personal data and information you provide to your dental practitioner will be handled in accordance with their individual privacy practices and/or policies. The information you provide may be required
to help your practitioner provide you with suitable treatment options. Please contact your dental practitioner for further information about the collection, processing, use, and distribution of your personal
data and information.

Invisalign® treatment is a series of clear plastic removable orthodontic aligners that gently move patients’ teeth. An orthodontist or Invisalign trained dentist will be able to advise whether Invisalign treatment
is right for you. You should always read and follow their directions for use. In rare cases, allergies may occur.

© 2022 Align Technology, Inc. All rights reserved.

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