Scribd
Upload
286 views

Dental Consultation Form

This dental consultation form summarizes a patient's dental exam. It includes the patient's personal details like name, age, sex, address, and contact number. The dental officer examined the patient and noted their chief complaint. The form documents the results of the exam, identifying any dental caries, fillings, unerupted teeth, or teeth recommended for extraction. It was signed by the examining dental officer and dated.

Uploaded by

Mae Gonzales
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
286 views

Dental Consultation Form

This dental consultation form summarizes a patient's dental exam. It includes the patient's personal details like name, age, sex, address, and contact number. The dental officer examined the patient and noted their chief complaint. The form documents the results of the exam, identifying any dental caries, fillings, unerupted teeth, or teeth recommended for extraction. It was signed by the examining dental officer and dated.

Uploaded by

Mae Gonzales
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Republic of the Philippines

SORSOGON STATE UNIVERSITY


Office of Student Development and Services
Health Services Unit
Magsaysay Street, Sorsogon City
E-mail Add.: [email protected]
DENTAL CONSULTATION FORM DIPLOMA IN
SHEENA MAE G. BAÑEZ
Name: ______________________ 29 y/o
Age: ________ MIDWIFERY-1ST YEAR
Course & Year/Designation: _____________
CARRIEDO, IROSIN, SOR. Sex: ________
Address:_____________________ FEMALE 09-4844-858-01
Contact Number: ______________________

Legend:

C – Dental Caries Co – Composite Filling Rf – Roof fragment Un – Un-erupted


X – Tooth for Extraction P – Pontic Am – Amalgam Filling
Case History:

Chief Complaint:

Examined by:

MEDIN J. NICOLAS, DMD __________________


Dental Officer III Date

You might also like