ORTHODONTIC REQUEST FORM

May I request from your good office the emergency or temporary treatment of my dear
patient, Daryl Merilles, to be attended due to the current situation of this pandemic.

I hereby request the temporary endorsement for any treatment on the following conditions:

1. Cutting or replacement of any impinging or poking wires

2. De bonded or popped out brackets or bondable buccal tubes
3. Decayed individual elastics or colored-ties
4. Re cementation of any bands
5. Oral prophylaxis when the condition call for

May I also request that any treatment necessary would necessitate that the undersigned be
informed thru a phone call 09177209422/09338686214 to better serve our patient and
professionally communicate with each other.

Please disclose any financial responsibility to the patient on the treatment to perform.

Indeed, grateful for the care and help to our patient.

Yours truly,

Dr. Andrea A. Dela Cruz

(Attending Orthodontic Practitioner)