Dental Treatment Plan Template Page 2
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2SECTION III - CONSULTATION REQUEST (To be completed by requesting officer)
CONSULTATION DESIRED
REMARKS (If appropriate)
(Indicate by check mark(s))
PROSTHODONTIC
23
PERIODONTIC
24
ORAL SURGERY
25
OPERATIVE
26
CROWN AND BRIDGE
27
OTHER (specify)
28
SECTION IV - CONSULTANT REMARKS AND RECOMMENDATIONS
29.
(Initial after each entry and identify entry by number)
APD LC v1.02 ES
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Parent category: Medical