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.

Sincerely,

Dr. _________