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Texas Workforce Commission Vocational Rehabilitation Services Dental Report The information requested is necessary to help counselors determine treatment needs for the person named. Return Information Return Report To (Name): Telephone Number: ( ) Address: City: State: ZIP Code: Name: Patient Information Date of Birth: Social Security Number: Telephone Number: ( ) Reported Disability: Reason for Referral: Examination and Treatment Record To the dentist: Examination authorization does not allow for proceeding with definitive dental care. Complete all applicable items and return for treatment authorization. Use charting system shown. One tooth number, one procedure, and one estimated fee per line. For prosthesis (fixed or removable), indicate teeth to be replaced. Tooth ADA Code Number Number Description of Services (Including X-rays, prophylaxis materials used, etc.) Estimated Fee DRS Use Only Mark “X” on the chart above to indicate missing teeth. DARS3108 (11/06) Page 1 of 2 Treatment period - number of months: Total Fee: Is any of the treatment for orthodontic purposes? Is the major dental condition: Yes No If prosthesis, is this initial placement? Yes acute slowly progressive static If no, reason for replacement: No Give summary statement of condition of mouth: Remarks for unusual services: All information is to be treated as confidential. Examinee has the legal right to see this report when the examinee requests. Type or Print Dentist's Name: Telephone Number: ( ) Dentist’s Address: City: State: ZIP Code: Examining Dentist’s Signature: Date of Examination: X DARS3108 (11/06) Dental Report (RSM 5) Page 2 of 2