Healthy Smiles Take a Team

Keeping our patients’ teeth healthy while in braces is a team effort! After your mutual patient’s hygiene visit, simply complete this form and submit it to our office.
Regular cleanings help our patients achieve their best smiles, and as a thank-you, you’ll also be entered into our monthly drawing for exciting prizes. That’s a win-win for everyone!

Patient Information

Patient's Name(Required)
MM slash DD slash YYYY

Clinical Notes

Homecare(Required)
Please contact me about this patient(Required)
Concerns from today's visit(Required)
I recommend the next hygiene visit be in(Required)
*Please coordinate with our office to have archwires removed for the next prophy.