Transfer of Care Summary (Orthodontics)

Header Fields

Date: [Date] Author: [Author name, credentials]

Practice/Site: [Practice name] — [Address / phone / secure email]

Transfer Type: [Transfer-Out / Transfer-In]

Patient Name: [Patient name] DOB: [DOB] Patient ID: [Patient ID]

Parent/Guardian: [Name and relationship] (Include only if patient is a minor)

Transfer Reason: [relocation / insurance change / provider change / clinical referral / other]

Orthodontic Start Date: [Start date] Date of Last Visit: [Date]

Receiving Provider/Practice: [Provider/practice name and contact info] (Include if known)

Referring Dentist: [Name and contact info] (Include if applicable)

Clinical Snapshot

[Narrative summary: baseline diagnosis with skeletal and dental classification, treatment modality, current phase and active corrections, key risks or issues encountered, recommended next step] (Write as a single paragraph of 3–6 sentences. Attribute information sources throughout. If details unavailable, state what is unknown.)

Diagnosis / Problem List

(Prioritize from highest to lowest clinical impact. For items not directly observed today, include source in parentheses. If diagnosis details unavailable, state: "Diagnosis details not provided in transfer records.")

• [Skeletal pattern: AP classification, vertical pattern, asymmetry] ([source])
• [Dental classification: molar/canine class, overjet/overbite] ([source])
• [Crowding/spacing by arch and severity] ([source])
• [Midline discrepancies] ([source])
• [Crossbites: location, type] ([source])
• [Impacted, ectopic, missing, or extracted teeth] ([source])
• [Periodontal or TMJ considerations] ([source])

Treatment Overview

[Summary of treatment plan and progress to date] (Attribute sources; if plan details unavailable, state what is unknown.)

Treatment Goals:

• [Goal 1]
• [Goal 2]
• [Goal 3]

(List 3–8 goals as applicable)

Planned Approach: (Include only if documented; attribute sources)

• [Extraction plan with teeth specified] ([source])
• [Expansion strategy/appliance] ([source])
• [Anchorage strategy] ([source])
• [Surgical plan status] ([source])
• [IPR plan for aligners] ([source])

Key Milestones: (Major events only; do not reproduce full progress history)

• [Date — Event description] ([source])
• [Date — Event description] ([source])

Current Treatment Status

(Document what is in the mouth as of today. Label observations vs. confirmed records using: "Observed [description]; not confirmed from records.")

Fixed Appliances: (Include if applicable)

• [Bracket system: slot size, prescription, brand] ([source])
• [Teeth bonded/banded; missing or broken brackets] ([source])
• [Auxiliaries: power chain, coil springs, lacebacks, ties, stops, bends] ([source])
• [Anchorage devices: TPA, Nance, lingual arch — active/passive] ([source])
• [TADs: location, purpose, engaged status] ([source])

Elastics: (Include if applicable)

• [Configuration, size/force, wear instructions, compliance] ([source])

Aligner Therapy: (Include if applicable)

• [Manufacturer/system and case identifier] ([source])
• [Current tray number of total trays; wear schedule] ([source])
• [Attachment locations and purpose] ([source])
• [IPR completed vs. planned] ([source])
• [Refinement status] ([source])

Current Archwires: (For fixed appliances; if unknown, state "Archwire not documented; observed [description]")

• Maxillary: [Wire size, material, form, date placed; special features; space closure method] ([source])
• Mandibular: [Wire size, material, form, date placed; special features; space closure method] ([source])

Issues & Complications

(If none known, state: "No significant issues or complications documented." Otherwise, list applicable items:)

• [Oral hygiene status / decalcification] ([source])
• [Bracket failures / cooperation concerns] ([source])
• [Periodontal concerns] ([source])
• [Root resorption concerns with imaging date] ([source])
• [TMJ symptoms and management] ([source])
• [Missed appointments / treatment gaps] ([source])
• [Adverse events] ([source])

Records Transfer

Authorization Status: [Authorized / Not yet obtained] — [Patient/guardian name, date obtained, recipient, delivery method] (State: "Originals retained per practice policy." If not authorized: "Authorization not yet obtained; records not released.")

Records Transmitted:

• [Radiographs: type, date, format]
• [Photographs: type, date, format]
• [Models/3D scans: type, date, format]
• [Cephalometric analysis/tracings: date, format]
• [Treatment plan documents: date, format]
• [Progress notes: date range, format]
• [Consultation letters: date, format]

Missing or Pending Records: [Record type, reason missing, request status with date, interim clinical plan if applicable]

Continuation Plan / Action List

1. [Action] — [Rationale]; [Timing]; [Responsible party]; [Contingency if applicable]
2. [Action] — [Rationale]; [Timing]; [Responsible party]; [Contingency if applicable]
3. [Action] — [Rationale]; [Timing]; [Responsible party]; [Contingency if applicable]

(Prioritize items. Examples: obtain updated imaging before torque changes; continue elastic protocol; replace missing brackets; request aligner case transfer; address hygiene concerns.)

Patient Communication

[Summary of discussion with patient/parent including understanding of transfer and acknowledgment that receiving provider may modify treatment plan]

• [Interim instruction: elastic wear / appliance care / emergency protocol]
• [Expected timeline for records transfer and next steps]

Signature

Author: [Name, credentials] Date/Time Signed: [Date and time]

Contact for Clinical Questions: [Phone or secure email]

(Use "Not available," "Not provided," or "Unknown" for missing essential elements. For pending records, document "Records requested / pending" with request date. Do not infer extraction patterns, IPR amounts, aligner staging, TAD specifications, wire sequences, root resorption status, or surgical plans without documentation. Attribute all information: "per records dated [date]," "per patient report," or "per clinical exam [date]." If a section cannot be completed, include brief explanation rather than leaving blank.)