12–17 Years Old Hygiene Template

RDH: [SELECT/INSERT: Hygienist]
RDA: [SELECT/INSERT: RDA]

Informed verbal consent given by [AUTO: Patient First Name] [AUTO: Patient Last Name] [SELECT/INSERT: CONSENT FOR TX] for treatment today.
Medical history reviewed: [SELECT/INSERT: MedHx/DentalHx]
Premedication Required: [SELECT/INSERT: PREMED]
Checked Cl 5 Indicators on all cassettes used for procedure as well as indicators on bagged instruments: [SELECT/INSERT: Cl5 Indicator Strip Checked]

Miele Sterilization Codes Scanned:

• Gingival Health-

• Plaque Index-

• Calculus- NO/YES  (If yes where- )

• Intraoral Images- YES/NO

• OHI Reviewed
Flossing Technique:
Brushing Technique:

Do they have a NightGuard?
Have they had orthodontics?
Do they wear Retainers? Fixed or removable?

Scaling? Yes or No   #__ units

Polish? Yes or No

Fluoride :  Yes or No

• Relayed info to parent or legal guardian: YES/NO

• Goal for next visit:

RDH/RDA Comments:
-ALL PROPER PPE WAS WORN DURING APPT AS PER AHS AND CRDHA GUIDELINES
Recall Interval: [SELECT/INSERT: REC RECALL INTERVAL]
Hygiene Interval: [SELECT/INSERT: REC HYGIENE INTERVAL]

Next Visit: [SELECT/INSERT: NEXT VISIT]
Date Booked: