SURGERY FOLLOW-UP

G E N E R A L PAT I E N T I N F O R M AT I O N

Date of follow-up visit Treatment Center

yyyy-mm-dd 

Please contact your Regional Manager to register additional treatment centers and

practitioners

Did the surgery site heal properly?

Yes No

If no were there any complications during or after this procedure that kept you If yes, please explain
from achieving an ideal outcome?

Yes No

Do you think this patient will need additional surgery? If yes, please explain

Yes No
Do you think this patient will need speech services? If yes, please explain

Yes No

Do you think this patient will need orthodontic treatment? If yes, please explain

Yes No

Is the child appropriate height/weight for his/her age?

Yes No

If no, has the child's nutritional status improved following surgery?

Yes No

If school aged, does the child attend school? If no, what treatment will improve the child's chances of attending school?

Yes No Not applicable

How does the patient/family feel about the course of treatment so far? How has life changed for the patient? (please describe)
PHOTOS

Follow-up Photo (Frontal Smiling)

File should be less than 50mb.

Follow-up Photo (Frontal Lip - If Applicable) (Optional) Follow-up Photo (Palate - If Applicable) (Optional)

File should be less than 50mb. File should be less than 50mb.

Other (Optional) Other (Optional)

File should be less than 50mb. File should be less than 50mb.