Dental Treatment Plan Template
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1
2DENTAL TREATMENT PLAN
YES
NO
CONSULTATION DESIRED
1.
For use of this form, see TB MED 250; proponent agency is Office of TSG.
(If yes, complete Section III, on reverse side)
SECTION I - PLANNED TREATMENT AND SEQUENCE OF ACCOMPLISHMENT
Check items in Column c to indicate treatment planned. If sequence of treatment is other than that printed in column b,
use numbers (1 thru 10) in column c to show desired order.
C
L
CHART
PLANNED
O
ACCOM-
I
Chart ONLY missing teeth and TREATMENT TO BE ACCOMPLISHED.
SE-
D
TYPE TREATMENT
PLISHED
N
QUENCE
E
Do NOT chart existing Pathology or Restorations.
E
a
b
c
d
e
A
2
URGENT
3
B
PERIODONTAL
4
C
PROPHYLAXIS
SnF2 PASTE
TOPICAL
SnF2
D
5
REPEAT AFTER
MONTHS
6
E
COUNSELING IN SELF CARE
1
2
3
4
5
6
7
8
9
10
11 12
13
14
15
16
F
OCCLUSION
7
32
31
30
29
28 27 26 25 24 23 22 21
20
19
18
17
8
G
SURGERY
9
H
RESTORATIONS
I
10
PROSTHESES
OTHER (specify)
11
J
12. REMARKS OR INSTRUCTIONS
Use this space for additional clarification of recommended treatment or for describing treatment which does not lend itself to charting.
Indicate nature of treatment and teeth or other tissues involved. Identify entry by code letter (Column a, above).
13. DATE
14. TREATMENT FACILITY
15. SIGNATURE OF DENTIST RECORDING TREATMENT
PLAN
SECTION II - PATIENT IDENTIFICATION
16. SEX
17. RACE
18. GRADE
19. ORGANIZATION
20. PATIENT'S LAST NAME - FIRST NAME - MIDDLE INITIAL
21. DATE OF BIRTH
22. IDENTIFICATION NUMBER
DA FORM 3984, DEC 1972
REPLACES DA FORM 8-276, 1 AUG 62 WHICH WILL BE USED.
APD LC v1.02ES
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