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Southern Smiles Orthodontics and Pediatric Dentistry Brand Element
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Orthodontic Office Forms

Informative and interactive office forms for McNutt Orthodontics are found on this page. Please do not hesitate to contact us if you have questions or if we can help in any way. Our administrative orthodontic dental team is separate from our pediatric dentistry administrative team. For pediatric office forms, CLICK HERE.

Ortho Forms
Financial & Insurance Policies
Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Financial & Insurance Policies

To review our Financial & Insurance Policies prior to your initial appointment, please click on and read the document below. We are happy to answer any questions that you may have about our policies and assist you in understanding your insurance coverage.

Orthodontic Patient
Records Release Form

There are circumstances where the law will require us to use a signed dental records release form in order for our practice to obtain a copy of dental records from another orthodontist, dentist or dental specialist. In the event you need a copy of our release form to complete and submit to your doctor, click on the Records Release Form button.

Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Click here to open and print the release form:

Orthodontic Patient Records Release Form
Southern Smiles Orthodontics and Pediatric Dentistry Brand Element

Retainer Replacement Form

To the left is an interactive form for patients who need a retainer replacement or possibly a repair of their retainer. For most retainer replacements, we will have the retainer made off of a 3D-printed model of your teeth. If you do not already have a 3D printed model of your teeth (we started making these available to patients after treatment starting in 2021), we will scan your teeth with our 3D camera system and use our in-house 3D printer to create the model of your teeth.

  • FOR OUR EXISTING PATIENTS: Complete the form to your left and submit it. If you do not hear back from us by the end of the next business day, please call the office.

  • FOR PATIENTS WE DID NOT PROVIDE TREATMENT FOR: We charge an evaluation fee that is paid in advance of scheduling, and we require that you complete and submit this form. If you do not hear back from us by the end of the next business day, please call the office.

  • We are able to provide retainer replacements, and we are able to repair most but not all types of permanent bonded wire retainers.

  • BRING YOUR RETAINERS & MODELS: Bring ALL your existing retainers and 3D printed models of your teeth to your evaluation appointment

Refer A Patient Or Friend

Many of our patients are referred to us directly by a family dentist and many of our existing patient families refer their friends and neighbors. We appreciate the trust and confidence you have shown in us! Whether you are a doctor or you are referring a friend or neighbor, you may use the interactive form below

Ortho Retainer Replacement Form
Ortho Refer A Patient Or Friend
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