At Hawaiian Smiles, we prioritize our mutual patient’s oral health with top-notch care. Our focus? Ensuring each patient’s gums are healthy, teeth are cavity-free, and they are informed about future dental plans, like veneers or crowns. "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Today's Date*Patient's Name*Patient's Date of Birth*Patient's Phone Number*Name of Referring Dentist*Dentist's Phone Number*Date of Last Maintenance Visit*Prior to starting or continuing orthodontic treatment, please contact patient to provide the following service(s):* Dental Exam and Cleaning Periodontal Clearance Dental Clearance Dental Restoration Other If 'other' please explain:*Please confirm patient is dentally and/or periodontally cleared to start or continue orthodontic treatment by signing below.Signature*Date Cleared:*Please add additional comments (if needed):
