EXAM & RECORD FORMS CLINICAL FORMS (341-6235) (341-6503) 2-SIDED RECORD FORMS (341-6576) * Streamline your patients' documentation with this comprehensive form * Printed on sturdy, 7 pt. return postcard stock * 11 " x 81⁄2 " in both vertical and horizonal formats Form �������������������������������������������������������������������� 100 per Pkg. 18.99 Specify: (341-6576) (341-6235) (341-6503) Back-Page 4 DENTAL RESTORATIONS & TREATMENTS SUBSEQUENT DISEASES & ABNORMALITIES REMARKS DATE REMARKS TOOTH SERVICE CHARGE PAID BALANCE Front Back DATE RE-EXAM RECORD WITH HEALTH HISTORY UPDATE * 2-sided form and smaller format keep records accurate and up to date * Features tooth charts on the front as shown * Printed on sturdy ledger stock * 51⁄2 " W x 81⁄2 " H (367-3432)�����������������������������������������������������������250 per Pkg. 48.99 DENTAL RECORD FORM SERVICE CHARGE PAID BALANCE Inside-Page 3 Front-Page 1 * 4-page medical/dental record * Detailed form captures all of your important clinical findings * Designed with space for clinical findings, patient histories, estimates, charting, charge information, and progress notes * Printed on offset opaque stock * 17 " W x 11 " H overall size, folds to 81⁄2 " W x 11 " H (369-0036) ������������������������������������������������������������� 50 per Pkg. 25.99 5 Pkg.@ 23.99 PERIODONTAL STATUS FORM * Comprehensive 1-sided form includes space to record clinical indicators * 2-hole punch at top * Printed with green ink * 81⁄2 " W x 11 " H (369-0024)�����������������������������������������������������������100 per Pkg. TOOTH Inside-Page 2 5 Pkg.@ 21.99 19.99 For Imprinted Materials, contact: professional.promotions@henryschein.com To order, visit: www.henryscheindental.com 145