|
Chief Complaint
|
|
|
NO Changes to Medical History
|
Changes to Medical History
|
|
|
Dental History
|
|
Premedication (Blank if NA)
|
|
|
Blood Pressure
/
|
Heart Rate:
|
|
Review Informed Consent & Signatures
|
|
|
START CHECK
|
|
|
Retake Radiographs
|
|
|
Forms (Perio First)
• • •
|
PAGE PERIO FACULTY
|
|
Perio Findings
|
Perio Faculty Name
|
|
Odontogram Charting
• • •
|
< 45 mins left. Reschedule pt
|
|
Problem List
|
Complete Treatment Plan Worksheet
|
|
Clinical Check By
|
Address pt concerns
|
|
Diagnostic Impressions (as needed)
|
|
|
Next Appointment (MM/DD)
/
|
Next Visit (Discuss TP or procedure)
|
|
Dismiss Patient
|
|
|
Additional Forms
• • •
|
|
|
Final Signature for TPW1 (Dr. Name)
|
|
