AVERIA DENTAL CLINIC

Dra. Josefa F. Averia, DMD and Dr. Reggie F. Averia, DMD

GENERAL DENTISTRY AND ORTHODONTICS
23 gov. Perez St. Brgy 04, Catanauan, Quezon
Contact us: 09496688821

DATE:

DENTAL CERTIFICATE
Patient: _____________________________________________ Birthdate: ____________

To whom it may concern,

This is to certify that I have attended the dental needs of Mr./Ms./Mrs.
_________________________________________, ______ years old, presently residing at
________________________________________________ had completed the following dental
procedures/services:

 Oral prophylaxis
 Extraction
 Permanent filling
 Temporary filling
 Root canal treatment
 Denture construction
 Jacket crown/bridge/fixed denture
 Consulation
 Dental radiograph
 Orthodontic treatment
 Surgery
 Others:

Recommendation/s:
______________________________________________________________________________
______________________________________________________________________________

This certification is issued upon the request of the patient for whatever purpose it may
serve, except medico-legal purposes

Dentist:
Lic. NO: _________________
PTR No: _________________