PERIO ROTATION EVALUATION FORM

KIRKWOOD DENTAL HYGIENE V

Complete the form below for EACH patient treated or observed during your rotation through
the Periodontics clinic. Turn in to faculty upon completion. Forms not turned in will result in
no credit for the rotation.

Name of Dental Hygi ene student , lB:Sira 6x

Date ;${.Q.i" .fg Perio Grad:br. fl.o"^.-.

Pi Proficiencies Performed :

Periodontal Case irt t :e i. rd

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Procedures Performed :.d ECe+ 0nn i rq
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. Grad Student evaluation of appointment/student performance:
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Perio Grad:
Pa Proficiencies Performed :

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 I

PERIO ROTATION EVALUATION FORM

KIRKWOOD DENTAL HYGIENE V

Complete the form below for EACH patient treated or observed during your rotation through
the Periodontics clinic. Turn in to faculty upon completion. Forms not turned in will result in
no credit for the rotation.

Name of Dental Hygi ene student . ie.:.,:,,i. ., fi:v

Date:2" Perio Grad , hli

Proficiencies Performed :

Periodontal Case Type:

Procedures Performed, tVarr.Lt\(\ I f., \r\11)16q,

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_ Grad Student evaluation of appointment/student performance:

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Proficiencies Performed :

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Procedures Performed:
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Grad Student eva I uatio n of a ppoi ntment/student performa nce :

Student Assessment of rotation: bfiw

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