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SERVICES RENDERED Date Treatment Facility S Exam / Sickcall / Chief Complaint P S R B/P T Pulse Pain Level 0-10 O Type Exam X-Rays BW / PANO / PA Health History Review Head / Neck Exam OCSE Other SEXTANT SCORE A Carious Teeth Incipient Perio P Treatment Required NO YES OHI / Prophy Surg Oper Endo Prosth PT Informed Dental Officer Stamp/Signature Gingivitis Acute / Chronic Localized / Generalized Mild / Moderate / Severe Periodontitis Acute / Chronic see below Dental Class circle one I II III I have been informed of the benefits risks and alternatives including no treatment of the treatment plan outlined above and I give my consent to receive this dental treatment and any associated dental anesthesia. Patient Signature PATIENT S NAME Last First Middle Initial SSN Sex Rank/Grade Date of Birth Status STANDARD FORM 603A-CG REV. PREVIOUS EDITION NOT USABLE AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD DENTAL - CONTINUATION SECTION III. ATTENDANCE RECORD 15. RESTORATIONS AND TREATMENTS Completed during service 16. SUBSEQUENT DISEASES AND ABNORMALITIES REMARKS 17. PREVIOUS EDITION NOT USABLE AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD DENTAL - CONTINUATION SECTION III. ATTENDANCE RECORD 15. RESTORATIONS AND TREATMENTS Completed during service 16. SUBSEQUENT DISEASES AND ABNORMALITIES REMARKS 17.

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