Referring Doctors

Miller Orthodontics - Doctor Referral Form> Rock Hill: 803.327.1144 Lake Wylie: 803.631.5508 Email: appointments@carolinaorthodontics.com This is to introduce , who has been referred for a complimentary (no charge) orthodontic examination. Patient Age Child      Adult Would you like us to contact the patient to setup an appointment? Yes      No If yes, please complete the following Home Phone:     Work Phone: Referred by Dr. Office Phone:     Chief Concerns Crowded Teeth    Spaced Teeth    Missing Teeth Protrusive Teeth    Retrusive Teeth    Crossbite Openbite    Deep Overbite    Underbite Overjet    Facial Growth    TMJ Dysfunction Tooth Alignment for Crown and Bridge.    Other:   Please indicate area of concern Baby Teeth:   A   B   C   D   E   F   G   H   I   J   T   S   R   Q   P   O   N   M   L   K Permanent Teeth:   1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

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