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BASIC SHEET FOR DENTAL CONTROL

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BASIC SHEET FOR DENTAL CONTROL

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Dental File

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BASIC SHEET FOR DENTAL CONTROL

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DENTISTRY SHEET

SURNAMES AND NAMES______________________________________________________AGE_

ADDRESS________________________________________________________________________________TEL AND/OR
__________________
PERSONAL HISTORY_______________________________________________________________________________
FAMILY BACKGROUND_______________________________________________________________________________
REASON FOR
LTATION____________________________________________________________________________________
DENTOGRAM

LIPS____ GUMS_ FLOOR OF

H__________________________
VASTIBULES____________________PALATE__________________________ CHEEKS______________________________
TONGUE_________________________ TMJ____________________________
SION_______________________________
REQUEST FOR EXAMS____________________________________________________________________________________
DATE TREATMENT PERFORMED COST PASS BALAN SIGNATURE
CE

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