Periodontal Recare

DENTIST: [SELECT/INSERT: Dentists]
RDA: [SELECT/INSERT: RDA]
Hygienist: [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: [SELECT/INSERT: MedHx/DentalHx]
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:

E/O - WNL
I/O - WNL
TMJ - WNL
Occlusion- WNL

Periodontal diagnosis
Gingivitis - (local)(general)/ (early)(advanced)(severe)
Periodontitis-(local)(general)/(early)(advanced)(severe)

PSR Max/Man:

Plaque (none)(light)(moderate)(heavy) in 03, 04, 05, 06, 07, 08
Stain (none)(light)(moderate)(heavy) in 03, 04, 05, 06, 07, 08
Calculus (none)(light)(moderate)(heavy) in 03, 04, 05, 06, 07, 08

Oral Hygiene (Excellent)(V.Good)(Good)(fair)(poor)
Compliance (Excellent)(V.Good)(Good)(fair)(poor)

Maint.Interval - Month____units____
Hyg. Instructions/ Recommended care-

Decay-


Midmark- ; Tutt-
Next Appointment: (6month)(3month) Hygiene
                                Recall Exam