TMJ Exam / Consult or Referral

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

Informed verbal consent given by [AUTO: Patient First Name] [AUTO: Patient Last Name] 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:

TREATMENT COMPLETED: Insert [AUTO: Th][AUTO: Description]

Section B Benefits Attending report:
Adjuster's contact:
Claim Number:

Imaging - Pan and Specific TMJ 2D imaging

Clinical exam:
TMJ:
Masseter:
Dental trauma (chipped teeth):

Comments:

Do they use a CPAP?

Does patient have a NightGuard?
Do they use NightGuard?

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

Doctor's Diagnosis:


Post-op management:
[SELECT/INSERT: TMJ Management Strategies]

Next Appointment