Summary of Dental Records
Dear Doctor __________________________:
Our former patient, ______________________________________________________, has requested that we review our records and x-rays, and forward them to your office. I have reviewed the records and have made notes which may be of assistance.
Copies of latest (__________BW's) ( __________FMX) (__________Panorex) x-rays sent.
Nothing of consequence noted in chart.
Last cleaning & exam was on __________________________.
Recall frequency of ___3 months ___4 months ___6 months ___12 months has been recommended.
Periodontal problems have been noted in these areas: _________________________________________________________
Notations on oral hygiene: _______________________________________________________________________________
Consultation with Periodontist has been: ___Recommended ___Completed (Dr. ___________________________).
Periodontal surgery was: ___Performed ___Recommended (Dr. ___________________________).
Pulp caps or deep restorations noted on teeth #__________________________.
Endodontic therapy has been recommended on teeth #_________________________________.
Consultation with Orthodontist has been: ___Recommended ___Completed (Dr. _________________________).
Extractions were recommended for teeth #_______________________________________.
Restorative services have been recommended but not completed on teeth # _______________________________________.
Crowns were recommended for teeth #_______________________________________________.
Cast restorations have been recemented on teeth #______________________________.
Implants have been recommended to replace teeth #_____________________________.
Fixed bridges have been recommended to replace teeth #______________________________.
Removable partial denture(s) have been recommended. ____Maxillary ____Mandibular
New full denture(s) have been advised. ____Maxillary ____Mandibular
Reline(s) have been advised. ____Maxillary ____Mandibular
Other concerns: _______________________________________________________________________________________
Please call me so we can discuss this case further.