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Get Terry Reilly Health Services Dental Provider Performance Review Form

Arter Reviewed__________________________ Dentist Reviewed: _______________________________ GENERAL CHART INFORMATION CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE YES YES YES NO NO YES NO YES NO NO 1. Patient Information complete? 2. General Consent complete? 3. Medical History complete? 4. Medical History update complete? 5. Are Allergies and Medical conditions documented? 6. Indicators discussed: caries risk ,Diabetes, smoking, etc.? Comments:___________________________.

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