Consultation Date
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Month
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Day
Year
Treating Doctor
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Dr. Omid Dianat
Dr. Fay Mansouri
Dr. Michelle Lee
Dr. Jimmy Pham
Patient Name
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Referred by
General Dentist
Chief Compliant
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EXAM
Exam
Exam
Exam
Tooth #
Subjective
Objective
Radiographic
Pocket Depth
Cold Test
Percussion
Palpation
Bite Sensitivity
Mobility
DIAGNOSIS
Tooth #
Pulpal Diagnosis
Periapical Diagnosis
Treatment Plan
Prognosis
Differential Diagnosis
Alternative Treatment
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