EXAM & RECORD FORMS CLINICAL FORMS (341-6235) (341-6503) 2-SIDED RECORD FORMS (341-6576) * Streamline your patients' documentation with this comprehensive form * Printed on sturdy, 7 pt. return postcard stock * 11 " x 81⁄2 " in both vertical and horizonal formats Form �������������������������������������������������������������������� 100 per Pkg. 18.99 Specify: (341-6576) (341-6235) (341-6503) Back-Page 4 DENTAL RESTORATIONS & TREATMENTS SUBSEQUENT DISEASES & ABNORMALITIES REMARKS DATE REMARKS TOOTH SERVICE CHARGE PAID BALANCE Front Back DATE RE-EXAM RECORD WITH HEALTH HISTORY UPDATE * 2-sided form and smaller format keep records accurate and up to date * Features tooth charts on the front as shown * Printed on sturdy ledger stock * 51⁄2 " W x 81⁄2 " H (367-3432)�����������������������������������������������������������250 per Pkg. 48.99 DENTAL RECORD FORM SERVICE CHARGE PAID BALANCE Inside-Page 3 Front-Page 1 * 4-page medical/dental record * Detailed form captures all of your important clinical findings * Designed with space for clinical findings, patient histories, estimates, charting, charge information, and progress notes * Printed on offset opaque stock * 17 " W x 11 " H overall size, folds to 81⁄2 " W x 11 " H (369-0036) ������������������������������������������������������������� 50 per Pkg. 25.99 5 Pkg.@ 23.99 PERIODONTAL STATUS FORM * Comprehensive 1-sided form includes space to record clinical indicators * 2-hole punch at top * Printed with green ink * 81⁄2 " W x 11 " H (369-0024)�����������������������������������������������������������100 per Pkg. TOOTH Inside-Page 2 5 Pkg.@ 21.99 19.99 For Imprinted Materials, contact: professional.promotions@henryschein.com To order, visit: www.henryscheindental.com 145http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416235%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416235 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416503%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416503 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416576%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416576 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416576%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416576 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416235%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416235 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3416503%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3416503 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3673432%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3673432 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3690036%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3690036 http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3690024%26CatalogName%3DDENTAL%26utm_source%3DDental%26utm_medium%3DNxtbook%26utm_campaign%3Dpracticemarketing20212022%26utm_term%3D3690024 http://www.henryscheindental.com