Dental Claim Form $0.00. )-246(Sore spots)]TJ 0 -1.125 TD [(altered speech and difficulty in eating are common prob)20(lems)15(. $cFUX2t.b1o-m'(acB2cOCihjTh_6l/F:$tf)Ouo.C;\q IV. 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. I also authorize the release of information related to the coverage of services (as described n this form)to the named dentist. )-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 \(apicoectom)15(y\). Radiographic Exam form . The Treatment Plan form allows for a written statement of the services that you plan to perform. .juu!.Tnbcq=F.-8Ym:^9QCQtB,.n4"f\Vj!Tit4^PnaK;o9EZ4Ecjp(n Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. h�bbd```b``Z"��d.������@$��d] "��@$�l ��`�f �+L�M` �����pF+c0�D��pH�~�� 螙 �� ��?�0 q] This type of form is used to obtain consent from patients or their parents for several medical procedures. The treatment performed must be the treatment to which the patient has consented. )-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(. %%EOF )-246(A)0( per)-25(manent reline)]TJ T* [(will be needed later)50(. )-196(The cost f)30(or this)]TJ T* [(procedure is not included in the initial denture f)30(e)0(e)15(. Dental Treatment Plan Form Template Use this digital dental treatment plan in your practice to better organize records and easily track patient dental history. )-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. %PDF-1.2 %���� )-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(. My questions have been answered to my satisfaction. )-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(. )]TJ T* (Immediate dentures \(placement of dentures immediately after)Tj T* [(e)30(xtr)10(actions\) ma)30(y be painful. 0 1. 55 0 obj <>stream )-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(. Quote; Diagnosis and Treatment Form. !XEi=bdN:mrV'-)kb_9]2^&BEc3L(L)PEd'" )-246(I understand that)]TJ T* [(significant sensitivity is a common after eff)30(ect of a ne)20(wly placed)]TJ T* [(filling. You can obtain consent for a “treatment plan”. H#G^.`^.R`SD1@%[ptamqCbLd.SMG8821?#c8);.g:(ZC'30pP;qrB-&%*TrhJcBe GaTsXfKeJkabul%P^JJgY"gqS[gKjNXDcTRRodL$:l?? Dental Practice Consulting Analysis Plan Implementation. 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.