Download Dental Report - Texas Workforce Commission

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Transcript
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