New Patient Package Accident Form - Dental

New Patient Package Accident Form

Parent’s Report

Patient Name

Accident Date?

How did the accident occur?

Is the patient in pain now?

Do pain relievers help the pain?

What type of medical care was necessary?

Remarks?

Dental Report: (to be filled out by dentist)

Teeth injured?

Mobility?

Bite?

X-ray finding?

Patient to return?

Treatment Rx?

Charges?

Remarks?

Visit - Date & Remarks

First Visit

Second Visit

Special Instruction