Patient Motivation for Treatment Form

Patiens often request changes in their bites or faces and relief form pain or discomfort. Please help us understand your problem by checking the following information. Please be specific (select the words more, less,forward, backward, longer, shorter, etc.):
The Teeth

If your teeth could be changed, how would you like them to change?

The Face

If your facial appearance could be changed, what would you change?


If you want to reduce pain or discomfort where it be located? Please be specific about the location; select right side, left side or both if they apply.

Realizing that successful treatment greatly depends upon the patients complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical / dental status, I will so inform this practice.


Be sure to bring the printed form with you on your first visit.