Patient Name
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First Name
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Email Address
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Previous Dental Office Phone Number
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Area Code
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All recent x-rays including BW's, Panorex, FMX/PA's
Date of last recall / recare examination
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Date of last Scaling
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Month
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Day
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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
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Name
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Date
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