Republic of the Philippines

BICOL STATE COLLEGE OF APPLIED SCIENCES AND TECHNOLOGY

City of Naga
Telephone No. (054) 4720416 Loc. 119
Fax No. (054) 4720415
OFFICE OF THE DIRECTOR FOR STUDENT DEVELOPMENT SERVICES
DENTAL CLINIC
DENTAL RECORD

Name :___________________________________________ Age : _________ Gender: ____________

Date of Birth :____________________________________ Marital Status: _____________________
Address :____________________________________ Program : _________________________
In case of emergency, please notify:
Name :____________________________________Tel./Mobile Number : ________________
Address :______________________________________________________________ _________

MEDICAL STATUS: (Please check if you have any of the following conditions )
_____ Hypertension _____ Diabetes _____ Heart Ailment
_____ Epilepsy _____ Bleeding Disorder _____ Asthma
_____ Lung Disease _____ Allergies _____ Tumor/Growth
_____ Liver Disease _____ Kidney Disease _____ Others
____________

ALL ABOVE INFORMATION ARE TRUE AND CORRECT.

_____________________________________
SIGNATURE OVER PRINTED NAME

DENTITION STATUS:
(To be filled up by a Dentist)

Legend : DC - Dental Caries LC - Light Cure TF - Temporary Filling FB – Fixed Bridge

AM - Amalgam Filling M - Missing due to extraction RF - Root Fragment PT- Primary Tooth
RD - Retained Deciduous Tooth RCT - Root Canal Tooth JC - Jacket Crown X- Indicated for Extraction
AB - Abutment P - Pontic UN - Un-erupted SP- Supernumerary

______________________________
DENTIST
License Number: ________________

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