Split Adult Hygiene — Part 1

Last Recall Date: [AUTO: Last Recall Date]

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

Checked Cl 5 Indicators on all cassettes used for procedure as well as indicators on bagged instruments: [SELECT/INSERT: Cl4 Indicator Strip Checked]

Miele Sterilization Codes Scanned:

Informed verbal consent given by [AUTO: Patient First Name] [AUTO: Patient Last Name] [SELECT/INSERT: CONSENT FOR TX] for treatment today.
REVIEWED COVID SCREENING CONSENT FORM: YES
Medical history reviewed: [SELECT/INSERT: MedHx/DentalHx]
Premedication Required: [SELECT/INSERT: PREMED]


Patient Chief Concern: [SELECT/INSERT: PATIENT CC]

Does patient have a NightGuard?
Do they use NightGuard?

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


EOE/IOE:

Gingival Assessment: