Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

Date

Dr. Orthodontist
Address
City, State  Zip

Dear Dr. Ortho:

You will be seeing our patient, Irida Bike for comprehensive orthodontic evaluation and treatment.

Irida had a motorized scooter accident on September 7, 2011.  She went to Sacred Heart Emergency Room.  The next day she saw Dr. Oral Surgeon.  He repositioned and splinted the injured teeth; splint was removed October 13th.  A copy of his report is enclosed.

Irida then saw Dr. Endodontist for root canal treatment of #8, 9, & 24.

I first saw Irida for evaluation on October 25th.  We built up #24 with a huge composite.  She still needs composites on 7, 8, & 9, but tooth alignment and occlusion would not allow for very good restorations.  I’m sending a copy of photos taken that day.

I am hoping that you will be able to initiate orthodontic treatment, and at least improve anterior alignment so I will be able to place composite restorations.

I need to see Irida one more time to remove the Cavit and seal #8 & 9 RC access holes with composites, preferably before you begin treatment. 

Please call me if you need any further information.

Sincerely,

Dr. ______