Hygiene Correspondence for Mutual Patients
Please return this form so that we may update our records after this patient's visit. Thank you.
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First Initial and Last Name *
Patient's Date of Birth *
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DD
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YYYY
Date seen in your office: *
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DD
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YYYY
Was a caries exam completed? *
This patient was seen for a: *
Required
Other therapies completed: *
Required
The following images were taken: *
Required
The patient's home care is: *
Restorative recommendations:
Please add any other concerns or comments here:
Patient's Next Scheduled Appointment:
MM
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DD
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YYYY
Doctor's Name: *
Hygienist's Name: *
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