|
Last Appt Date (to be filled out by previous Dentist) |
· Treatment History (Complete Oral Exam) |
_____________________ |
· Treatment History (Recall Exam) |
_____________________ |
· Treatment History (Hygiene/Scaling) |
_____________________ |
· X-Rays (Bitewing) |
_____________________ |
· X-Rays (Full Mouth) |
_____________________ |
· X-Rays (Panorex/Panoramic) |
_____________________ |
· Any additional medical history, dental history, test results, photographs and/or radiographs (upon request by the dental practice) |
_____________________ |