7Lg )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 547.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 547.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(7)-7(. )-246(A)0( per)-25(manent reline)]TJ T* [(will be needed later)50(. +:pCX:kZ;*,=G9E1?AV:SO&:Z\m_$(dpnY)-:P(qZUR3J(-WU48/J5fM1ngs8U?eM )-246(I)0( giv)25(e m)15(y)0( per)-25(mission to the Dentist to mak)20(e an)15(y/all)]TJ T* [(changes and additions as necessar)-30(y)100(. "S+;k;RhC"fAVE3 Dental Treatment Plan – A type of treatment plan that is centered on dental care and would usually depend on the patient’s overall dental condition. )]TJ 0 -3.325 TD [(Signature of P)40(atient_______________________________________________________________)-1000(Date____________)]TJ 0 -2.4 TD [(Signature of P)40(arent/Guardian if patient is a minor_______________________________________ Date____________)]TJ ET Q endstream endobj 4 0 obj << /ProcSet [/PDF /Text ] /Font << /F6 5 0 R /F7 6 0 R /F9 7 0 R >> /ExtGState << /GS1 8 0 R /GS2 9 0 R >> >> endobj 11 0 obj << /Type /Halftone /HalftoneType 1 /HalftoneName (Default) /Frequency 60 /Angle 45 /SpotFunction /Round >> endobj 12 0 obj << /Type /Halftone /HalftoneType 5 /Red 13 0 R /Green 14 0 R /Blue 15 0 R /Gray 16 0 R /Cyan 13 0 R /Magenta 14 0 R /Yellow 15 0 R /Black 16 0 R /Default 16 0 R >> endobj 16 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 70.711 /Angle 45 /SpotFunction /Round >> endobj 15 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 66.667 /Angle 0 /SpotFunction /Round >> endobj 14 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 63.246 /Angle 18.435 /SpotFunction /Round >> endobj 13 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 63.246 /Angle 71.565 /SpotFunction /Round >> endobj 8 0 obj << /Type /ExtGState /SA false /OP false /HT /Default >> endobj 9 0 obj << /Type /ExtGState /SA false /OP true /HT 12 0 R >> endobj 17 0 obj << /Type /FontDescriptor /Ascent 720 /CapHeight 720 /Descent -178 /Flags 262176 /FontBBox [-167 -232 1007 1013] /FontName /HPIPCF+Helvetica-Black /ItalicAngle 0 /StemV 208 /XHeight 524 /CharSet (/six/L/hyphen/W/T/seven/M/period/X/A/ampersand/B/N/Y/eight/C/O/nine/zero/D/P/parenleft/one/space/E/two/parenright/F/R/three/G/S/four/I/U/H/five/comma/V) /FontFile3 18 0 R >> endobj 18 0 obj << /Filter [/ASCII85Decode /FlateDecode] /Length 3321 /Subtype /Type1C >> stream h�bbd```b``Z"��d.������@$��d] "��@$�l ��`�f �+L�M` �����pF+c0�D��pH�~�� 螙 �� ��?�0 q] !`,qAP8W$tgqS\1'fG8pUC^ER'L0Q>p;]U+?WpU*=K"Ij0S!X`Qec-etl9_5&JoKIbcRoR0luj[3p')sK@Fem\Cd16MBV_j_8L:qOqHtJ2Y! )-246(I fur)-40(ther understand)]TJ T* [(that I ma)30(y be w)10(ear)-15(ing tempor)10(ar)-30(y cro)15(wns)15(, which ma)30(y come off)]TJ T* [(easily and that I m)10(ust be careful to ensure that the)20(y are k)20(ept on)]TJ T* [(until the per)-25(manent cro)15(wns are deliv)25(ered. %%EOF treatment. 1. Dental Patient Treatment Plan forms, 5.5 x 8.5 Record patient conditions, recommended services and fees in one, compact and convenient form. It shows that you planned for the conditions you diagnosed, prioritized your treatment, and used a logical approach to providing treatment. laboratory costs are approximate. 165,339 total views, 25 views today. )-246(I ha)20(v)25(e)0( had the oppor)-40(tunity to read this f)30(o)0(r)-25(m)0( and ask questions)15(. dental hygiene treatment outcomes. 2.0 Dental charting N/A Yes No 2.1 Odontogram completed for patient exam and updated for recall exam: (pre-existing treatment, teeth present and missing, current oral conditions, etc.) You should therefore ensure that the treatment plan is broad enough to cover all of the specific treatments you provide. )-246(I)]TJ T* [(understand that most dentures require relining appro)30(ximately)]TJ T* [(three to tw)10(elv)25(e months after initial placement. Dental Practice Consulting Analysis Plan Implementation. Care and Treatment required Surname Forename Patient’s details NHS Personal Dental Treatment Plan The dentist named on this form is providing you with a course of treatment. 36. Patient Name_____ Birth date_____ Please read and initial the items below. PLANNED SE-QUENCE ACCOM-PLISHED CHART. D E. a TYPE TREATMENT. DRUGS AND MEDICA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 606.763 m 194.735 606.763 l S BT 8 0 0 8 194.735 607.483 Tm (TIONS)Tj ET 194.735 606.763 m 222.721 606.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 598.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw (I understand that antibiotics and analgesics and other)Tj 0 -1.125 TD (medications can cause allergic reactions causing redness and)Tj T* [(s)30(w)10(elling of tissues)15(, pain, itching, v)25(omiting, and/or anaph)30(ylactic)]TJ T* [(shoc)20(k \(se)30(v)25(ere allergic reaction\). )-246(I)]TJ T* [(understand that a more e)30(xpensiv)25(e filling that initially diagnosed)]TJ T* [(ma)30(y be required due to additional deca)30(y)100(. CONSULTATION DESIRED (If yes, complete Section III, on reverse side) L I. N E. C O. I have been informed of the treatment plan and associated fees. I also authorize the release of information related to the coverage of services (as described n this form)to the named dentist. )-551(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 457.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 457.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(8)-7(. The agreement commonly starts after successful work on the patient’s teeth have been completed. Information regarding your NHS dental treatment is detailed overleaf. i understand that the fees listed on this claim may not be covered by or may exceed my benefits plan i understand that i am financially responsible to my dentist for the entire cost of the treatment. DENTURES, COMPLETE OR P)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 210.763 m 231.114 210.763 l S BT 8 0 0 8 231.114 211.483 Tm (AR)Tj ET 231.114 210.763 m 243.417 210.763 l S BT 8 0 0 8 243.417 211.483 Tm (TIAL)Tj ET 243.417 210.763 m 263.862 210.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 202.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I realiz)15(e that full or par)-40(tial dentures are ar)-40(tificial, constr)-15(ucted of)]TJ 0 -1.125 TD [(plastic)15(, metal, and/or porcelain. 0 33 0 obj <>/Filter/FlateDecode/ID[<9511481D317806D8688C9333BA1FDE9C>]/Index[10 46]/Info 9 0 R/Length 110/Prev 181890/Root 11 0 R/Size 56/Type/XRef/W[1 3 1]>>stream )-7( ENDODONTIC )7(TREA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 547.038 m 459.223 547.038 l S BT 8 0 0 8 459.223 547.758 Tm 0.033 Tw (TMENT \(ROOT CANAL\))Tj ET 459.223 547.038 m 557.923 547.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 538.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I realiz)15(e there is no guar)10(antee that root canal treatment will sa)20(v)25(e)]TJ 0 -1.125 TD [(m)15(y)0( tooth, and that complications can occur from the treatment,)]TJ T* (and that occasionally metal objects are cemented in the tooth or)Tj T* [(e)30(xtend through the root, which does not necessar)-15(ily aff)30(ect the)]TJ T* (success of the treatment, I understand that occasionally)Tj T* [(additional surgical procedures ma)30(y be necessar)-30(y f)30(ollo)15(wing root)]TJ T* [(canal treatment \(apicoectom)15(y\). You should go over the Dental (Patient) Consent Form in full and answer any questions the patient may have clearly. Care and Treatment required Surname Forename Patient’s details Personal Dental Treatment Plan The dentist named on this form is providing you with a course of treatment. )-7( FILLINGS)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 376.038 m 414.811 376.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 367.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that care m)10(ust be e)30(x)30(ercised in che)20(wing on fillings)]TJ 0 -1.125 TD [(especially dur)-15(ing the first 24 hours to a)20(v)25(oid breakage)15(. My questions have been answered to my satisfaction. For use of this form, see TB MED 250; proponent agency is Office of TSG. GaTsXfKeJkabul%P^JJgY"gqS[gKjNXDcTRRodL$:l?? 3GB1kP:J5XdNp.$7ON-nF-B0i-BR[S*=bOj"M _____ OFFICE VERIFICATION D ATE PREPARED THIS ESTIMATE IS VALID UNTIL STANDARD DENTAL TREATMENT FORM APPROVED BY THE CANADIAN DENTAL ASSOCIATION )-196(The cost f)30(or this)]TJ T* [(procedure is not included in the initial denture f)30(e)0(e)15(. Order 5 or more and receive 10% off. Nursing Care Plan Form. )-246(Sore spots)]TJ 0 -1.125 TD [(altered speech and difficulty in eating are common prob)20(lems)15(. )]TJ T* (Immediate dentures \(placement of dentures immediately after)Tj T* [(e)30(xtr)10(actions\) ma)30(y be painful. If any individual Order 10 or more and receive 15% off. )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 309.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 310.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(5. 100 forms per tablet. professional for the purpose of treatment, payment, or health care operations, including submission of a claim for dental benefits to a provider or administrator of dental benefit plans. ORAL HEALTHCARE KNOWLEDGE LEVEL OF H EPA TI N Before planning individualized patient care, an attempt is m a d et os hp i ’ r lk w g v . Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. )-246(I understand the r)-15(isks)]TJ T* [(in)20(v)25(olv)25(ed in ha)20(ving teeth remo)15(v)25(ed, some of which are pain,)]TJ T* [(s)30(w)10(elling, spread of inf)30(ection, dr)-30(y soc)20(k)20(et, loss of f)30(eeling in m)15(y)]TJ T* [(teeth, lips)15(, tongue and surrounding tissue \(P)40(aresthesia\) that can)]TJ T* [(last f)30(or an indefinite per)-15(iod of time \(da)30(ys or months\) or fr)10(actured)]TJ T* [(ja)20(w)60(. Claim Forms; Consent Forms; Dental Emergency Forms; Dental History Forms; Gingivitis / Periodontal Forms; HIPPA Forms; HIPPA Labels; Medical Release Forms; )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 543.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 544.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(3. Standard Dental Treatment Form — 39.2 KB The Canadian Dental Association is the nation's voice for dentistry dedicated to the promotion of optimal oral health, an essential component of general health, and to the advancement of a unified profession. )-7( PERIODONT)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 457.038 m 425.652 457.038 l S BT 8 0 0 8 425.652 457.758 Tm 0.033 Tw (AL LOSS \(TISSUE & BONE\))Tj ET 425.652 457.038 m 542.831 457.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 448.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that care m)10(ust be e)30(x)30(ercised in che)20(wing on fillings)]TJ 0 -1.125 TD [(especially dur)-15(ing the first 24 months to a)20(v)25(oid breakage)15(. 8;USO%9+&)(#_im.\6gmW\,j The main thing is that the patient understands any risks involved before they consent to treatment. White c… )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 210.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 211.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(6. )-246(My questions ha)20(v)25(e)0( been)]TJ T* [(ans)30(w)10(ered to m)15(y)0( satisf)30(action. )-246(I realiz)15(e the final)]TJ T* [(oppor)-40(tunity to mak)20(e changes in m)15(y)0( ne)20(w cro)15(wn, br)-15(idge)15(, or cap)]TJ T* [(\(including shape)15(, fit, siz)15(e and color\) will be bef)30(ore cementation. g&7b4B9`bA'Y(scU&%!H*'ZkEX[0,b]cs1TqVk]/MM1&r38#6LKSQLm7&B4dmW`eB 2 Dental Treatment Plan Template free download. 'g=Yb[P/(,_g )-246(I understand remo)15(ving teeth does)]TJ T* [(not alw)15(a)30(ys remo)15(v)25(e)0( all the inf)30(ection, if present, and it ma)30(y be)]TJ T* [(necessar)-30(y to ha)20(v)25(e)0( fur)-40(ther treatment. 0"LrO[A2pQeB2H5X=u5qoOhmDOV17'9[BSad'G>],8`&N#lf&[6jf'qgh#V'CV9Ri )-246(I consent to the proposed treatment. You can obtain consent for a “treatment plan”. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. )-246(I)0( understand that f)30(ailure to k)20(eep m)15(y)0( deliv)25(er)-30(y)]TJ T* [(appointment ma)30(y result in poor)-15(ly fix)30(ed dentures)15(. 3 31. 51Ss"):ts>5;QG[HGSVtK\6tA#47? endstream endobj 11 0 obj <> endobj 12 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Type/Page>> endobj 13 0 obj <>stream )-246(I understand I ma)30(y need fur)-40(ther treatment b)20(y)0( a specialist or)]TJ T* [(e)30(v)25(en hospitalization if complications ar)-15(ise dur)-15(ing or f)30(ollo)15(wing)]TJ T* [(treatment, the cost of which is m)15(y)0( responsibility)100(. For patients under the age of 18, a parent or guardian will need to sign the consent form. Includes universal tooth chart for easy notations and referencing. GK]H1N? endstream endobj startxref h��k�\����JL��� 0`[�c ��w��AP��=�, �����O� i�a�H�"Y�;c:�C�����z�z�����!�zH�R;$�H� o3@NFQ'#hS>`t;;S!.J;aN3$il[S//kPi!hIm,?B>q2sKjiFDJ32e/aWk$.YB4.i6C*F(O,LpVL@L6be8JN`YtT^XlG"?LWOD62l`!/&Vha$=@LQ )-246(I)0( ac)20(kno)15(wledge that no guar)10(antee or assur)10(ance has been made b)20(y)0( an)15(y)20(one regarding the dental treatment which I)]TJ T* [(ha)20(v)25(e)0( requested and author)-15(iz)15(ed. However, any treatment you perform must be covered by this treatment plan. )-246(I understand that)]TJ T* [(significant sensitivity is a common after eff)30(ect of a ne)20(wly placed)]TJ T* [(filling. Information on plan - ning dental hygiene interventions for the patient who uses tobacco is found on pages __ to __. :N& I have had the opportunity to read this form and ask questions. )-246(If a remak)20(e is)]TJ T* [(required due to m)15(y)0( dela)30(ys of more than 30 da)30(ys there will be)]TJ T* [(additional charges)15(. $cFUX2t.b1o-m'(acB2cOCihjTh_6l/F:$tf)Ouo.C;\q Dental Forms. )-246(I)]TJ T* [(understand that a more e)30(xpensiv)25(e filling that initially diagnosed)]TJ T* [(ma)30(y be required due to additional deca)30(y)100(. Recare Exam form . )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 295.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 295.758 Tm 0 0 0 1 k /GS2 gs -0.005 Tc 0.038 Tw [(10. @?Tsb-NRCTV^,rdtm&Vb;Wc=t!C6>[\MFWm!\7dup"+2,$WQU^=L\S`sg[t!Wbs'OSi0`A7S/S1IFd5*qO).pN"QVT1]+15!,UC_SM0bA!H'e'Nt?J9/8SHYY.I6B;_HK9G,pos>69XR IV. )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 376.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 376.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(9)-7(. This type of form is used to obtain consent from patients or their parents for several medical procedures. Treatment Plan worksheet . Financial arrangement and treatment planning for patients in a dental practice is a critical component of overall practice management. Fill, sign and download Dental Treatment Plan Template online on Handypdf.com )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 462.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 463.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(4. The Treatment Plan form allows for a written statement of the services that you plan to perform. Consent for Dental Treatment Pediatric: Consent for Safety Steps Pediatric: Patient Management Techniques ... Quality Assessment Plan Self Management Goals – CODPHE Cavity Free at Three. Information regarding your NHS dental treatment is detailed overleaf. Claim Form for Dental Treatment Reimbursements For the quickest way of submitting your claim, log into Health Hub at www.aetnainternational.com and submit your claim online. Makes up to 5 copies at a time. no date of treatment should appear on this form. Download free printable Dental Treatment Plan Template samples in PDF, Word and Excel formats X-RA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 633.763 m 124.593 633.763 l S BT 8 0 0 8 124.593 634.483 Tm (YS)Tj ET 124.593 633.763 m 136.591 633.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 141.481 634.483 Tm 0 0 0 1 k /GS2 gs 0 Tc (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 606.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 607.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(2. )-246(I)0( realiz)15(e the final oppor)-40(tunity to)]TJ T* [(mak)20(e changes in m)15(y)0( ne)20(w dentures \(including shape)15(, fit, siz)15(e)15(,)]TJ T* [(placement, and color\) will be the )30(\322teeth in w)15(ax\323)-266(tr)-30(y-in visit. CROWNS, BRIDGES AND CAPS)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 309.763 m 237.942 309.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 301.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that sometimes it is not possib)20(le to match the color)]TJ 0 -1.125 TD [(of natur)10(al teeth e)30(xactly with ar)-40(tificial teeth. )-196(The prob)20(lems of w)10(ear)-15(ing these)]TJ 33.75 55.534 TD [(appliances ha)20(v)25(e)0( been e)30(xplained to me)15(, including looseness)15(,)]TJ 0 -1.125 TD [(soreness)15(, and possib)20(le breakage)15(. Endodontics Exam/Treatment form . treatment form to my insurance company or its agents. 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Spain Temperature Map, Google Cloud Architect Vs Data Engineer, Wolf Vs Hyena Size, Julius Caesar Act I, Scene Iii L 140 141, Switch Off Meaning In Tamil, Banana Before Football, Where To Buy Silver Lace Vine, White Bugs On Cabbage Plant, Download Best Themes Free DownloadFree Download ThemesDownload Nulled ThemesDownload Best Themes Free Downloadonline free coursedownload lava firmwareDownload Themes Freefree download udemy paid courseCompartilhe!" /> 7Lg )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 547.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 547.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(7)-7(. )-246(A)0( per)-25(manent reline)]TJ T* [(will be needed later)50(. +:pCX:kZ;*,=G9E1?AV:SO&:Z\m_$(dpnY)-:P(qZUR3J(-WU48/J5fM1ngs8U?eM )-246(I)0( giv)25(e m)15(y)0( per)-25(mission to the Dentist to mak)20(e an)15(y/all)]TJ T* [(changes and additions as necessar)-30(y)100(. "S+;k;RhC"fAVE3 Dental Treatment Plan – A type of treatment plan that is centered on dental care and would usually depend on the patient’s overall dental condition. )]TJ 0 -3.325 TD [(Signature of P)40(atient_______________________________________________________________)-1000(Date____________)]TJ 0 -2.4 TD [(Signature of P)40(arent/Guardian if patient is a minor_______________________________________ Date____________)]TJ ET Q endstream endobj 4 0 obj << /ProcSet [/PDF /Text ] /Font << /F6 5 0 R /F7 6 0 R /F9 7 0 R >> /ExtGState << /GS1 8 0 R /GS2 9 0 R >> >> endobj 11 0 obj << /Type /Halftone /HalftoneType 1 /HalftoneName (Default) /Frequency 60 /Angle 45 /SpotFunction /Round >> endobj 12 0 obj << /Type /Halftone /HalftoneType 5 /Red 13 0 R /Green 14 0 R /Blue 15 0 R /Gray 16 0 R /Cyan 13 0 R /Magenta 14 0 R /Yellow 15 0 R /Black 16 0 R /Default 16 0 R >> endobj 16 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 70.711 /Angle 45 /SpotFunction /Round >> endobj 15 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 66.667 /Angle 0 /SpotFunction /Round >> endobj 14 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 63.246 /Angle 18.435 /SpotFunction /Round >> endobj 13 0 obj << /Type /Halftone /HalftoneType 1 /Frequency 63.246 /Angle 71.565 /SpotFunction /Round >> endobj 8 0 obj << /Type /ExtGState /SA false /OP false /HT /Default >> endobj 9 0 obj << /Type /ExtGState /SA false /OP true /HT 12 0 R >> endobj 17 0 obj << /Type /FontDescriptor /Ascent 720 /CapHeight 720 /Descent -178 /Flags 262176 /FontBBox [-167 -232 1007 1013] /FontName /HPIPCF+Helvetica-Black /ItalicAngle 0 /StemV 208 /XHeight 524 /CharSet (/six/L/hyphen/W/T/seven/M/period/X/A/ampersand/B/N/Y/eight/C/O/nine/zero/D/P/parenleft/one/space/E/two/parenright/F/R/three/G/S/four/I/U/H/five/comma/V) /FontFile3 18 0 R >> endobj 18 0 obj << /Filter [/ASCII85Decode /FlateDecode] /Length 3321 /Subtype /Type1C >> stream h�bbd```b``Z"��d.������@$��d] "��@$�l ��`�f �+L�M` �����pF+c0�D��pH�~�� 螙 �� ��?�0 q] !`,qAP8W$tgqS\1'fG8pUC^ER'L0Q>p;]U+?WpU*=K"Ij0S!X`Qec-etl9_5&JoKIbcRoR0luj[3p')sK@Fem\Cd16MBV_j_8L:qOqHtJ2Y! )-246(I fur)-40(ther understand)]TJ T* [(that I ma)30(y be w)10(ear)-15(ing tempor)10(ar)-30(y cro)15(wns)15(, which ma)30(y come off)]TJ T* [(easily and that I m)10(ust be careful to ensure that the)20(y are k)20(ept on)]TJ T* [(until the per)-25(manent cro)15(wns are deliv)25(ered. %%EOF treatment. 1. Dental Patient Treatment Plan forms, 5.5 x 8.5 Record patient conditions, recommended services and fees in one, compact and convenient form. It shows that you planned for the conditions you diagnosed, prioritized your treatment, and used a logical approach to providing treatment. laboratory costs are approximate. 165,339 total views, 25 views today. )-246(I ha)20(v)25(e)0( had the oppor)-40(tunity to read this f)30(o)0(r)-25(m)0( and ask questions)15(. dental hygiene treatment outcomes. 2.0 Dental charting N/A Yes No 2.1 Odontogram completed for patient exam and updated for recall exam: (pre-existing treatment, teeth present and missing, current oral conditions, etc.) You should therefore ensure that the treatment plan is broad enough to cover all of the specific treatments you provide. )-246(I)]TJ T* [(understand that most dentures require relining appro)30(ximately)]TJ T* [(three to tw)10(elv)25(e months after initial placement. Dental Practice Consulting Analysis Plan Implementation. Care and Treatment required Surname Forename Patient’s details NHS Personal Dental Treatment Plan The dentist named on this form is providing you with a course of treatment. 36. Patient Name_____ Birth date_____ Please read and initial the items below. PLANNED SE-QUENCE ACCOM-PLISHED CHART. D E. a TYPE TREATMENT. DRUGS AND MEDICA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 606.763 m 194.735 606.763 l S BT 8 0 0 8 194.735 607.483 Tm (TIONS)Tj ET 194.735 606.763 m 222.721 606.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 598.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw (I understand that antibiotics and analgesics and other)Tj 0 -1.125 TD (medications can cause allergic reactions causing redness and)Tj T* [(s)30(w)10(elling of tissues)15(, pain, itching, v)25(omiting, and/or anaph)30(ylactic)]TJ T* [(shoc)20(k \(se)30(v)25(ere allergic reaction\). )-246(I)]TJ T* [(understand that a more e)30(xpensiv)25(e filling that initially diagnosed)]TJ T* [(ma)30(y be required due to additional deca)30(y)100(. CONSULTATION DESIRED (If yes, complete Section III, on reverse side) L I. N E. C O. I have been informed of the treatment plan and associated fees. I also authorize the release of information related to the coverage of services (as described n this form)to the named dentist. )-551(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 457.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 457.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(8)-7(. The agreement commonly starts after successful work on the patient’s teeth have been completed. Information regarding your NHS dental treatment is detailed overleaf. i understand that the fees listed on this claim may not be covered by or may exceed my benefits plan i understand that i am financially responsible to my dentist for the entire cost of the treatment. DENTURES, COMPLETE OR P)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 210.763 m 231.114 210.763 l S BT 8 0 0 8 231.114 211.483 Tm (AR)Tj ET 231.114 210.763 m 243.417 210.763 l S BT 8 0 0 8 243.417 211.483 Tm (TIAL)Tj ET 243.417 210.763 m 263.862 210.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 202.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I realiz)15(e that full or par)-40(tial dentures are ar)-40(tificial, constr)-15(ucted of)]TJ 0 -1.125 TD [(plastic)15(, metal, and/or porcelain. 0 33 0 obj <>/Filter/FlateDecode/ID[<9511481D317806D8688C9333BA1FDE9C>]/Index[10 46]/Info 9 0 R/Length 110/Prev 181890/Root 11 0 R/Size 56/Type/XRef/W[1 3 1]>>stream )-7( ENDODONTIC )7(TREA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 547.038 m 459.223 547.038 l S BT 8 0 0 8 459.223 547.758 Tm 0.033 Tw (TMENT \(ROOT CANAL\))Tj ET 459.223 547.038 m 557.923 547.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 538.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I realiz)15(e there is no guar)10(antee that root canal treatment will sa)20(v)25(e)]TJ 0 -1.125 TD [(m)15(y)0( tooth, and that complications can occur from the treatment,)]TJ T* (and that occasionally metal objects are cemented in the tooth or)Tj T* [(e)30(xtend through the root, which does not necessar)-15(ily aff)30(ect the)]TJ T* (success of the treatment, I understand that occasionally)Tj T* [(additional surgical procedures ma)30(y be necessar)-30(y f)30(ollo)15(wing root)]TJ T* [(canal treatment \(apicoectom)15(y\). You should go over the Dental (Patient) Consent Form in full and answer any questions the patient may have clearly. Care and Treatment required Surname Forename Patient’s details Personal Dental Treatment Plan The dentist named on this form is providing you with a course of treatment. )-7( FILLINGS)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 376.038 m 414.811 376.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 367.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that care m)10(ust be e)30(x)30(ercised in che)20(wing on fillings)]TJ 0 -1.125 TD [(especially dur)-15(ing the first 24 hours to a)20(v)25(oid breakage)15(. My questions have been answered to my satisfaction. For use of this form, see TB MED 250; proponent agency is Office of TSG. GaTsXfKeJkabul%P^JJgY"gqS[gKjNXDcTRRodL$:l?? 3GB1kP:J5XdNp.$7ON-nF-B0i-BR[S*=bOj"M _____ OFFICE VERIFICATION D ATE PREPARED THIS ESTIMATE IS VALID UNTIL STANDARD DENTAL TREATMENT FORM APPROVED BY THE CANADIAN DENTAL ASSOCIATION )-196(The cost f)30(or this)]TJ T* [(procedure is not included in the initial denture f)30(e)0(e)15(. Order 5 or more and receive 10% off. Nursing Care Plan Form. )-246(Sore spots)]TJ 0 -1.125 TD [(altered speech and difficulty in eating are common prob)20(lems)15(. )]TJ T* (Immediate dentures \(placement of dentures immediately after)Tj T* [(e)30(xtr)10(actions\) ma)30(y be painful. If any individual Order 10 or more and receive 15% off. )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 309.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 310.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(5. 100 forms per tablet. professional for the purpose of treatment, payment, or health care operations, including submission of a claim for dental benefits to a provider or administrator of dental benefit plans. ORAL HEALTHCARE KNOWLEDGE LEVEL OF H EPA TI N Before planning individualized patient care, an attempt is m a d et os hp i ’ r lk w g v . Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. )-246(I understand the r)-15(isks)]TJ T* [(in)20(v)25(olv)25(ed in ha)20(ving teeth remo)15(v)25(ed, some of which are pain,)]TJ T* [(s)30(w)10(elling, spread of inf)30(ection, dr)-30(y soc)20(k)20(et, loss of f)30(eeling in m)15(y)]TJ T* [(teeth, lips)15(, tongue and surrounding tissue \(P)40(aresthesia\) that can)]TJ T* [(last f)30(or an indefinite per)-15(iod of time \(da)30(ys or months\) or fr)10(actured)]TJ T* [(ja)20(w)60(. Claim Forms; Consent Forms; Dental Emergency Forms; Dental History Forms; Gingivitis / Periodontal Forms; HIPPA Forms; HIPPA Labels; Medical Release Forms; )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 543.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 544.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(3. Standard Dental Treatment Form — 39.2 KB The Canadian Dental Association is the nation's voice for dentistry dedicated to the promotion of optimal oral health, an essential component of general health, and to the advancement of a unified profession. )-7( PERIODONT)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 373.855 457.038 m 425.652 457.038 l S BT 8 0 0 8 425.652 457.758 Tm 0.033 Tw (AL LOSS \(TISSUE & BONE\))Tj ET 425.652 457.038 m 542.831 457.038 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 324 448.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that care m)10(ust be e)30(x)30(ercised in che)20(wing on fillings)]TJ 0 -1.125 TD [(especially dur)-15(ing the first 24 months to a)20(v)25(oid breakage)15(. 8;USO%9+&)(#_im.\6gmW\,j The main thing is that the patient understands any risks involved before they consent to treatment. White c… )]TJ T* (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 210.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 211.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(6. )-246(My questions ha)20(v)25(e)0( been)]TJ T* [(ans)30(w)10(ered to m)15(y)0( satisf)30(action. )-246(I realiz)15(e the final)]TJ T* [(oppor)-40(tunity to mak)20(e changes in m)15(y)0( ne)20(w cro)15(wn, br)-15(idge)15(, or cap)]TJ T* [(\(including shape)15(, fit, siz)15(e and color\) will be bef)30(ore cementation. g&7b4B9`bA'Y(scU&%!H*'ZkEX[0,b]cs1TqVk]/MM1&r38#6LKSQLm7&B4dmW`eB 2 Dental Treatment Plan Template free download. 'g=Yb[P/(,_g )-246(I understand remo)15(ving teeth does)]TJ T* [(not alw)15(a)30(ys remo)15(v)25(e)0( all the inf)30(ection, if present, and it ma)30(y be)]TJ T* [(necessar)-30(y to ha)20(v)25(e)0( fur)-40(ther treatment. 0"LrO[A2pQeB2H5X=u5qoOhmDOV17'9[BSad'G>],8`&N#lf&[6jf'qgh#V'CV9Ri )-246(I consent to the proposed treatment. You can obtain consent for a “treatment plan”. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. )-246(I)0( understand that f)30(ailure to k)20(eep m)15(y)0( deliv)25(er)-30(y)]TJ T* [(appointment ma)30(y result in poor)-15(ly fix)30(ed dentures)15(. 3 31. 51Ss"):ts>5;QG[HGSVtK\6tA#47? endstream endobj 11 0 obj <> endobj 12 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Type/Page>> endobj 13 0 obj <>stream )-246(I understand I ma)30(y need fur)-40(ther treatment b)20(y)0( a specialist or)]TJ T* [(e)30(v)25(en hospitalization if complications ar)-15(ise dur)-15(ing or f)30(ollo)15(wing)]TJ T* [(treatment, the cost of which is m)15(y)0( responsibility)100(. For patients under the age of 18, a parent or guardian will need to sign the consent form. Includes universal tooth chart for easy notations and referencing. GK]H1N? endstream endobj startxref h��k�\����JL��� 0`[�c ��w��AP��=�, �����O� i�a�H�"Y�;c:�C�����z�z�����!�zH�R;$�H� o3@NFQ'#hS>`t;;S!.J;aN3$il[S//kPi!hIm,?B>q2sKjiFDJ32e/aWk$.YB4.i6C*F(O,LpVL@L6be8JN`YtT^XlG"?LWOD62l`!/&Vha$=@LQ )-246(I)0( ac)20(kno)15(wledge that no guar)10(antee or assur)10(ance has been made b)20(y)0( an)15(y)20(one regarding the dental treatment which I)]TJ T* [(ha)20(v)25(e)0( requested and author)-15(iz)15(ed. However, any treatment you perform must be covered by this treatment plan. )-246(I understand that)]TJ T* [(significant sensitivity is a common after eff)30(ect of a ne)20(wly placed)]TJ T* [(filling. Information on plan - ning dental hygiene interventions for the patient who uses tobacco is found on pages __ to __. :N& I have had the opportunity to read this form and ask questions. )-246(If a remak)20(e is)]TJ T* [(required due to m)15(y)0( dela)30(ys of more than 30 da)30(ys there will be)]TJ T* [(additional charges)15(. $cFUX2t.b1o-m'(acB2cOCihjTh_6l/F:$tf)Ouo.C;\q Dental Forms. )-246(I)]TJ T* [(understand that a more e)30(xpensiv)25(e filling that initially diagnosed)]TJ T* [(ma)30(y be required due to additional deca)30(y)100(. Recare Exam form . )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 295.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 295.758 Tm 0 0 0 1 k /GS2 gs -0.005 Tc 0.038 Tw [(10. @?Tsb-NRCTV^,rdtm&Vb;Wc=t!C6>[\MFWm!\7dup"+2,$WQU^=L\S`sg[t!Wbs'OSi0`A7S/S1IFd5*qO).pN"QVT1]+15!,UC_SM0bA!H'e'Nt?J9/8SHYY.I6B;_HK9G,pos>69XR IV. )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 324.84 376.058 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 360 376.758 Tm 0 0 0 1 k /GS2 gs -0.007 Tc 0.04 Tw [(9)-7(. This type of form is used to obtain consent from patients or their parents for several medical procedures. Treatment Plan worksheet . Financial arrangement and treatment planning for patients in a dental practice is a critical component of overall practice management. Fill, sign and download Dental Treatment Plan Template online on Handypdf.com )-246(\(Initials_____________\))]TJ ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 462.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 463.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(4. The Treatment Plan form allows for a written statement of the services that you plan to perform. Consent for Dental Treatment Pediatric: Consent for Safety Steps Pediatric: Patient Management Techniques ... Quality Assessment Plan Self Management Goals – CODPHE Cavity Free at Three. Information regarding your NHS dental treatment is detailed overleaf. Claim Form for Dental Treatment Reimbursements For the quickest way of submitting your claim, log into Health Hub at www.aetnainternational.com and submit your claim online. Makes up to 5 copies at a time. no date of treatment should appear on this form. Download free printable Dental Treatment Plan Template samples in PDF, Word and Excel formats X-RA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 633.763 m 124.593 633.763 l S BT 8 0 0 8 124.593 634.483 Tm (YS)Tj ET 124.593 633.763 m 136.591 633.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 141.481 634.483 Tm 0 0 0 1 k /GS2 gs 0 Tc (\(Initials_____________\))Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F9 1 Tf 14 0 0 14 54.84 606.783 Tm 0 0 0 1 k /GS2 gs (n)Tj 1 Tr 0 0 0 1 K 0 J 0 j 0.24 w 10 M []0 d 0 0 TD (n)Tj 0 Tr 0 0 0 0 k -0.06 0.05 TD (n)Tj 1 Tr 0 0 TD (n)Tj ET Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F6 1 Tf 8 0 0 8 90 607.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.033 Tw [(2. )-246(I)0( realiz)15(e the final oppor)-40(tunity to)]TJ T* [(mak)20(e changes in m)15(y)0( ne)20(w dentures \(including shape)15(, fit, siz)15(e)15(,)]TJ T* [(placement, and color\) will be the )30(\322teeth in w)15(ax\323)-266(tr)-30(y-in visit. CROWNS, BRIDGES AND CAPS)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 309.763 m 237.942 309.763 l S Q q 1 i 0 792 612 -792 re 0 792 m W n 0 792.06 612 -792 re W n BT /F7 1 Tf 8 0 0 8 54 301.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that sometimes it is not possib)20(le to match the color)]TJ 0 -1.125 TD [(of natur)10(al teeth e)30(xactly with ar)-40(tificial teeth. )-196(The prob)20(lems of w)10(ear)-15(ing these)]TJ 33.75 55.534 TD [(appliances ha)20(v)25(e)0( been e)30(xplained to me)15(, including looseness)15(,)]TJ 0 -1.125 TD [(soreness)15(, and possib)20(le breakage)15(. Endodontics Exam/Treatment form . treatment form to my insurance company or its agents. 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dental treatment plan form pdf

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