DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PATIENT NAME
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PARENT / LEGAL GAURDIAN
PARENT/LEGAL GUARDIAN
PHONE
ADDRESS
INSURANCE
REASON FOR REFERRAL
1st dental visit
Toothache
Decay
Special needs
Trauma
Sedation/Anesthesia
High anxiety
RADIOGRAPHS
None available
X-rays uploaded
X-rays emailed
DATE X-RAYS TAKEN
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TOOTH CHART
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
T
S
R
Q
P
O
N
M
L
K
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
COMMENTS
REFERRING DOCTOR
REFERRING DOCTOR NAME
PHONE
EMAIL
UPLOAD YOUR X-RAYS HERE
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