Aao Transfer Form PDF Details

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Here is some data that may be useful in case you are seeking to determine just how long it'll require you to fill out aao transfer form and just how many PDF pages it includes.

QuestionAnswer
Form NameAao Transfer Form
Form Length3 pages
Fillable?Yes
Fillable fields130
Avg. time to fill out26 min 45 sec
Other namesorthodontic transfer form, aao transfer form, aao form online, aao orthodontic transfer form

Form Preview Example

AAO TRANSFER FORM

PATIENT IN ACTIVE TREATMENT

Date _______________

To ____________________________________________________

From __________________________________________________

Phone ___________________ Fax __________________ Email: __________________________________________________

Patient's name _______________________________________ Birth date ____________________ Sex _________________

Social Security # __________________________ Phone ___________________

Responsible party __________________________________ Relationship: ____________________

Home address __________________________City _________________ State/Province ____________ Zip code __________

ANALYSIS (Including significant history & TMD) ________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

PATIENT/PARENT CONCERNS RE: TX _______________________________________________________________________

SPECIAL HEALTH OR HISTORY CONCERNS ___________________________________________________________________

TREATMENT PLAN (Including chronology of treatment rendered) _________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

TREATMENT PROGRESS (Including chronology of treatment rendered)____________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

APPLIANCES

Fixed appliance:

Type_______________ Manufacturer _____________ Type of bracket: † metal or † non-metal Variations__________

Date bands and/or brackets placed: Max_______ Mand _______ Bonding Agent _______ Cementing Agent _________

Current archwire size and type: Max ______________ Mand _________________

Intraoral elastics: dates initiated, size and direction_____________________ Hours requested______________________

Extraoral appliance:

Type________________ and dates initiated______________________ Hours requested ____________________________

Removable appliance:

Type and dates initiated______________________________ Hours requested _________________________

Clear tray appliance:

Manufacturer _______________ Total trays ______ Trays delivered______ Change interval __________________________

Case/Patient number______________________

PATIENT COOPERATION

Oral hygiene __________________________________________ Headgear _________________________________________

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© American Association of Orthodontists 2014

Elastics ______________________________________________ Clear trays _______________________________________

Appointments _________________________________________ Broken appliances ________________________________

Patient's attitude toward treatment ________________________________________________________________________

Suggestions for patient motivation _________________________________________________________________________

ACTIVE TX TIME ESTIMATES Original _________________________ Remaining _____ % of active treatment completed

RECOMMENDATIONS FOR CONTINUED TREATMENT __________________________________________________________

______________________________________________________________________________________________________

RECOMMENDATIONS FOR RETENTION _____________________________________________________________________

ADDITIONAL COMMENTS _______________________________________________________________________________

_____________________________________________________________________________________________________

FINANCIAL

Closed ______________ Open End (Fixed) _______________Other ______________________

Fees: Active _______________ Extras ______________________________________________

Terms ________________________________________________________________________

Third party payment ____________________________________________________________

Total charges before transfer _________________________

Total amount paid before transfer _____________________

Unpaid amount still owed transferring office ____________

Balance of original quoted fee not yet charged ______________ or overpaid at transfer ______________

This patient/parent has been advised that orthodontic treatment fees vary widely throughout the country and the world and it is reasonable for them to expect that a transfer may increase treatment fees and may involve changes in payment policies. For most people who transfer during their orthodontic treatment, the total treatment cost is likely to increase.

AVAILABLE RECORDS FOR TRANSFER

 

Casts

Initial

† Date ________

Progress † Date ________ Articulator type________

Ceph

Initial † Date ________

Progress † Date ________

Tracings

Initial

† Date ________

Progress † Date ________

Panoramic

Initial † Date ________

Progress † Date ________

CBCT

Initial † Date ________

Progress † Date ________

Intra-oral scan

Initial

† Date ________

Progress † Date ________

files

 

 

 

Intraoral x-rays

Initial

† Date ________

Progress † Date ________

Facial photos

Initial † Date ________

Progress † Date ________

Intraoral photos

Initial † Date ________

Progress † Date ________

Check appropriate status of records:

Record duplicates sent upon request (may be an additional charge to patient) † Yes † No

Records enclosed † Yes † No Records sent under separate cover † Yes † No

Signature: __________________________________________________Date_______________________

(Orthodontist)

2

© American Association of Orthodontists 2014

REQUEST TO TRANSFER RECORDS TO NEW PROVIDER

When a patient moves, or, for other reasons, there is a necessity to change orthodontists during the course of ongoing orthodontic treatment, it is highly advantageous for all involved parties that the transfer be as prompt and convenient as possible. Of paramount importance is the identification of an orthodontist who will accept the patient and successfully complete the treatment.

The American Association of Orthodontists represents over ninety percent of the orthodontic specialists in the U.S. and Canada. Your current doctor is a member and will assist you in finding a qualified orthodontist.

It is necessary that your records be transferred to assure that the receiving orthodontist is knowledgeable of your orthodontic condition(s), orthodontic treatment goals, the current treatment plan, and related financial arrangements. To facilitate the transfer of these records, it is necessary that you complete the following:

I authorize Dr. ____________________ to release all records of ____________________ (patient’s name) for the

purpose of continuation of treatment by Dr. ___________________(new provider’s name).

Signature: __________________________________________________________Date_______________________

(Patient or Guardian)

Print Name ________________________________________

Relationship to Patient ______________________________

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© American Association of Orthodontists 2014

How to Edit Aao Transfer Form Online for Free

The PDF editor you will make use of was designed by our best computer programmers. It is possible to prepare the aao transfer form 2021 file fast and efficiently using this app. Simply keep up with this particular procedure to start out.

Step 1: The first thing will be to click the orange "Get Form Now" button.

Step 2: At the moment, you can start editing your aao transfer form 2021. The multifunctional toolbar is readily available - insert, remove, modify, highlight, and undertake other commands with the words and phrases in the file.

Prepare all of the following segments to prepare the template:

portion of fields in aao transfer

In the APPLIANCES, Type, and, dates, initiated, Hours, requested and Type, and, dates, initiated, Hours, requested field, write down the information you have.

aao transfer APPLIANCES, TypeanddatesinitiatedHoursrequested, and TypeanddatesinitiatedHoursrequested blanks to fill

Type in any information you are required within the section Oral, hygiene, Headgear and American, Association, of, Orthodontists

aao transfer OralhygieneHeadgear, and AmericanAssociationofOrthodontists fields to fill

The Patients, attitude, toward, treatment Fees, Active, Extras and Terms segment will be used to write down the rights or responsibilities of both sides.

part 4 to filling out aao transfer

Review the sections and next fill them out.

aao transfer  fields to fill out

Step 3: Select the button "Done". Your PDF document is available to be transferred. You can obtain it to your computer or email it.

Step 4: Generate copies of the form - it will help you keep away from potential future concerns. And fear not - we are not meant to reveal or check your details.

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