Rudey Orthodontics - Doctor Referral Form This is to introduce , who has been referred for a complimentary (no charge) orthodontic examination. Child      Adult 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