Patient Name*
*
First Name
Last Name
Previous Dental Office Phone Number *
*
-
Area Code
Phone Number
All recent x-rays including BW's, Panorex, FMX/PA's
Date of last recall / recare examination
-
Month
-
Day
Year
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Date of last Scaling
-
Month
-
Day
Year
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Copies of Periodontal charting
Recall Interval
6 Months
9 Months
Scaling interval recommended
3 Months
4 Months
6 Months
9 Months
Annually
Other concerns or comments
Signature ( Patient, Parent / Guardian)*
*
Name*
*
First Name
Last Name
Date*
*
-
Month
-
Day
Year
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