|
Follow Up?
|
New Patient?
|
|
Chief Complaint
• • •
|
* Duration (Present for the past___)
|
|
*Prior Treatments:
• • •
|
*Current Treatments:
• • •
|
|
Painful?
|
Secondary Infection
• • •
|
|
|
Additional Notes:
|
|
Clinical Drawing
|
Clinical Photo Obtained?
|
|
|
|
|
Non Covered Services:
• • •
|
|
