Emergency Exam

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

Informed verbal consent given by [AUTO: Patient First Name] [AUTO: Patient Last Name] [SELECT/INSERT: CONSENT FOR TX] for treatment today.

MEDICAL history reviewed & INCLUDES: [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:

Treatment completed today:

Do they have and use a CPAP?

Does patient have a Splint?
Do they use Splint?

Have they had orthodontics?
Do they wear Retainers? Fixed or removable?

Do they have Partial Dentures

is there anything they would like to improve with their smile/teeth?

Additional Comment:


Doctor's Diagnosis:

Treatment Options:



Treatment Plan:



Requested Preauthorization to be sent by administration team.

Next Visit: [UNRESOLVED PLACEHOLDER: NEXT VISIT]
Date Booked: