CLINICAL FORMS EXAM & RECORD FORMS Back Back Front Front EXAM/ACCOUNT RECORD FORM * Front of this 2-sided form features " 1-32 " numbering, " a-t " lettering, and an area to summarize patient history * Back side has space to list services needed or rendered and fees * Printed on sturdy ledger stock * 81⁄2 " x 101⁄2 " horizontal (367-3430)�����������������������������������������������������������250 per Pkg. 53.99 (369-0034) Opaque Stock GEOMETRIC EXAM RECORD FORM * Front has tooth charts as shown, with an area for clinical data and medical/dental history summaries * Back has space for necessary services and their fees * 81⁄2 " x 11 " horizontal (367-9820)�����������������������������������������������������������250 per Pkg. 53.99 Front CLINICAL PATIENT CHARTS * Letter-size chart allows for plenty of space to record comprehensive, permanent patient records * 2-sided form includes room for clinical findings, patient histories, and charge information, among others * Printed with green ink on 80 Lb. offset opaque stock or heavy-duty, 110 Lb. index card stock * 81⁄2 " W x 11 " H 80 Lb. Opaque Stock (369-0034) �������������������������������������������������������������100 per Pkg. 5 Pkg.@ 22.99 20.99 Back 146 To order, visit: www.henryscheindental.com