dental treatment plan form pdf

.juu!.Tnbcq=F.-8Ym:^9QCQtB,.n4"f\Vj!Tit4^PnaK;o9EZ4Ecjp(n Patient Name_____ Birth date_____ Please read and initial the items below. 'g=Yb[P/(,_g Dental Patient Treatment Plan forms, 5.5 x 8.5 Record patient conditions, recommended services and fees in one, compact and convenient form. CONSULTATION DESIRED (If yes, complete Section III, on reverse side) L I. N E. C O. My questions have been answered to my satisfaction. !`,qAP8W$tgqS\1'fG8pUC^ER'L0Q>p;]U+?WpU*=K"Ij0S!X`Qec-etl9_5&JoKIbcRoR0luj[3p')sK@Fem\Cd16MBV_j_8L:qOqHtJ2Y! dental patient treatment plan forms, dental health printable worksheets and dental treatment plan worksheet are three main things we … )-246(\(Initials_____________\))]TJ -29.25 -8.796 TD [(I understand that dentistr)-30(y is not an e)30(xact science and that, theref)30(ore)15(, reputab)20(le pr)10(actitioners cannot fully guar)10(antee)]TJ 0 -1.125 TD [(results)15(. )-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(. Information regarding your NHS dental treatment is detailed overleaf. )-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(. )-246(Sore spots)]TJ 0 -1.125 TD [(altered speech and difficulty in eating are common prob)20(lems)15(. You can obtain consent for a “treatment plan”. White c… dental hygiene treatment outcomes. Zno)Jg,eU1SVJh#GKDSXELl,2a7G>k*k-)nJZ[@gIJSj65R'><4XTF>,DjoP#'VU4 Download free printable Dental Treatment Plan Template samples in PDF, Word and Excel formats endstream endobj startxref Treatment plans are like maps and guides to take the patient to a healthy and happy place. Improvement Plan Sample Parenting Plan Template Lesson Plan Template Flight Plan Form Home Buyers' Plan Funeral Planning Dental Treatment Plan Template Daily Planner Template Corrective Action Plan Template Pension Plan Application Form Business Plan Form Implementation Plan ... Login to download the PDF. REMOV)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 462.763 m 135.697 462.763 l S BT 8 0 0 8 135.697 463.483 Tm (AL OF TEETH)Tj ET 135.697 462.763 m 194.873 462.763 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 54 454.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(Alter)-25(nativ)25(es to remo)15(v)25(al ha)20(v)25(e)0( been e)30(xplained to me \(root canal)]TJ 0 -1.125 TD [(ther)10(ap)30(y)100(,)0( cro)15(wns)15(, and per)-15(iodontal surger)-30(y)100(,)0( etc.\) and I author)-15(iz)15(e the)]TJ T* [(Dentist to remo)15(v)25(e)0( the f)30(ollo)15(wing teeth and an)15(y others necessar)-30(y)]TJ T* [(f)30(or reasons in par)10(ag)10(r)10(aph #3. Testimonials; Contact. )-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(. +:pCX:kZ;*,=G9E1?AV:SO&:Z\m_$(dpnY)-:P(qZUR3J(-WU48/J5fM1ngs8U?eM ����'�V)Q�i�c8�r��|H����j*h��� ;���UH9���x�5�I*��]}��g�>{{������xZ�������������k�:����̟O�:�w�ꛟ^__���_>8�������+W�}�����!�__}����o����P}�zr=~C���ų�����^�~��l�� ��r�F;��g?޼������T��ُ�W~�͟�x�;kg�Oo�\�~��՟_��qV};�I�]}y����w�����5kt{��Z�CS�}s���՛����Ⱦۄ�+������V�|��o��. )-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(. )]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. 1 g /GS1 gs 0 792 m 0 792 l f 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 16 0 0 16 137.705 726.481 Tm 0 0 0 1 k /GS2 gs 0 Tc (DENT)Tj ET 0 0 0 1 K 0 J 0 j 0.928 w 10 M []0 d 137.705 725.041 m 185.393 725.041 l S BT 16 0 0 16 185.393 726.481 Tm 0.033 Tw (AL TREA)Tj ET 185.393 725.041 m 260.89 725.041 l S BT 16 0 0 16 260.89 726.481 Tm (TMENT CONSENT FORM)Tj ET 260.89 725.041 m 474.295 725.041 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 90 697.281 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(Dentist\325)50(s Name_________________________________ P)40(atient\325)50(s Name:____________________________________)]TJ 0 -2.5 TD [(Please read and initial the items chec)20(k)20(ed belo)15(w and read and sign at the bottom of f)30(o)0(r)-25(m)0(. fN'TC=Ht1sc2@fKW#%aG&^_"M8s29^tStrSfB=lgNi]T$)q:7.`-u:[YF]. 0"LrO[A2pQeB2H5X=u5qoOhmDOV17'9[BSad'G>],8`&N#lf&[6jf'qgh#V'CV9Ri I also authorize the release of information related to the coverage of services (as described n this form)to the named dentist. )-246(I understand that)]TJ T* [(significant sensitivity is a common after eff)30(ect of a ne)20(wly placed)]TJ T* [(filing. The agreement binds the dental office and patient for a payment schedule that is often paid on a weekly or monthly basis. "-Qa'Dp4Kd"MNHc-pV@s\"tZWnZ=q50B0p`i7H*r_fg5^"01[CEC)qS.Sh1LSX`FrgPUYtKgPB:)ZQt`$a,FYc]A5dj )]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 The treatment performed must be the treatment to which the patient has consented. )-246(Immediate dentures ma)30(y require)]TJ T* [(consider)10(ab)20(le adjusting and se)30(v)25(e)0(r)10(al relines)15(. )-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(. How to complete this form One form must be completed for each claimant, for each dental condition treated. PRE-TREATMENT ESTIMATE NOTE: ALL INFORMATION MUST BE PRINTED Completed Forms to: Prominence Health Plan, Medicare Resolution Desk 1510 Meadow Wood Lane Reno, NV 89502 Email: [email protected] Facsimile: (775) 770-9001 Member Name: First MI Last SEX M … 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. )-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(. %%EOF 0 I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. 3 31. The main thing is that the patient understands any risks involved before they consent to treatment. 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 Consent for Dental Treatment Pediatric: Consent for Safety Steps Pediatric: Patient Management Techniques ... Quality Assessment Plan Self Management Goals – CODPHE Cavity Free at Three. REMARKS OR … $cFUX2t.b1o-m'(acB2cOCihjTh_6l/F:$tf)Ouo.C;\q )]TJ T* (Immediate dentures \(placement of dentures immediately after)Tj T* [(e)30(xtr)10(actions\) ma)30(y be painful. 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 )-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 \(apicoectom)15(y\). )-246(I)]TJ T* [(understand that it is m)15(y)0( responsibility to retur)-25(n f)30(or deliv)25(er)-30(y of the)]TJ T* [(dentures)15(. 55 0 obj <>stream A treatment plan must have realistic and measurable goals. I have been informed of the treatment plan and associated fees. Information regarding your NHS dental treatment is detailed overleaf. 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DENTURES)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 379.191 295.038 m 427.688 295.038 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 8 324 286.758 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand the w)10(ear)-15(ing of dentures is difficult. 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. )-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(. IV. 8;USO%9+&)(#_im.\6gmW\,j 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 \(se)30(v)25(ere allergic reaction\). H#G^.`^.R`SD1@%[ptamqCbLd.SMG8821?#c8);.g:(ZC'30pP;qrB-&%*TrhJcBe 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. Perio Recall Report form . ... *Cigna dental plans are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, GaTsXfKeJkabul%P^JJgY"gqS[gKjNXDcTRRodL$:l?? 1. Treatment Plan Forms; About. Makes up to 5 copies at a time. Fill, sign and download Dental Treatment Plan Template online on Handypdf.com 36. You should therefore ensure that the treatment plan is broad enough to cover all of the specific treatments you provide. )]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. CHANGES IN TREA)]TJ ET 0 0 0 1 K 0 J 0 j 0.464 w 10 M []0 d 103.855 543.763 m 186.729 543.763 l S BT 8 0 0 8 186.729 544.483 Tm (TMENT PLAN)Tj ET 186.729 543.763 m 245.192 543.763 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 54 535.483 Tm 0 0 0 1 k /GS2 gs 0 Tc 0.028 Tw [(I understand that dur)-15(ing treatment it ma)30(y be necessar)-30(y to change)]TJ 0 -1.125 TD [(or add procedures because of conditions f)30(ound while w)10(o)0(r)-15(king on)]TJ T* [(the teeth that w)10(ere not disco)15(v)25(ered dur)-15(ing e)30(xamination, the most)]TJ T* [(common being root canal ther)10(ap)30(y f)30(ollo)15(wing routine restor)10(ativ)25(e)]TJ T* [(procedures)15(. )-246(A)0( per)-25(manent reline)]TJ T* [(will be needed later)50(. )-246(I consent to the proposed treatment. 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. 2.2 Periodontal assessment completed as required 2.3 Treatment plan recorded 3.0 … )-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. 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. Dental Forms. 165,339 total views, 25 views today. Includes universal tooth chart for easy notations and referencing. )-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. 100 forms per tablet. However, any treatment you perform must be covered by this treatment plan. Financial arrangement and treatment planning for patients in a dental practice is a critical component of overall practice management. 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. h�bbd```b``Z"��d.������@$��d] "��@$�l ��`�f �+L�M` �����pF+c0�D��pH�~�� 螙 �� ��?�0 q] D E. a TYPE TREATMENT. )-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(. printed on #50 White 8.5 x 11; 2 sided with black ink; 500 per package; Request a Quote. 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Conditions you diagnosed, prioritized your treatment, and used a logical approach to providing treatment and easily track dental! - PLANNED treatment and SEQUENCE of ACCOMPLISHMENT plans have been explained to me, including surgery. Appear on this form, see TB MED 250 ; proponent agency is office of.! Plan form allows for a payment schedule that is often paid on weekly... Each claimant, for each dental condition treated … the treatment plan and associated fees easy notations and referencing ''! And easily track patient dental history detailed overleaf proposed treatment 15 % off questions the patient to a healthy happy...

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