Dental Ordering
Instructions to Cashier
Total Unbilled Amount :
Total Billed Amount :

Order History

Treatment Plan
Previous Treatment Plan
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
Mob  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
Mob  

Treatment Plan History

Examination
Previous Examination
Ref. Hospital
Previous Examination
ExtraOral Exam
Lymph Nodes

Others, Specify
Periodontal Screening
If any abnormalities please specify below
Gingival Soft Tissue (Generalized or localizes)
Color
Margins
Papillae
Consistency
Architecture
IntraOral Exam
If any abnormalities please specify below
Lips
Cheeks
Tongue
Pharynx
FOM
Others
Probing
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
Mob  
  8 7 6 5 4 3 2 1   1 2 3 4 5 6 7 8
Poc  
Rec  
Mob  

Examination History

Perio Chart

Diagnosis History

Impacted distal
Impacted mesial
Abcess
Unerepted tooth
Watch tooth
Caries/Decay
Incipient caries
congenittaly missing
Creacked tooth
Fractured tooth
Open contact distal
Open contact mesial
Hypersensitive
Recession
Abrassion
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