Clinic Treatment Plan

OLD clinic treatment PLAN

PRE-OPERATIVE MEDICAL SCREENING & PLANNING

Dr Koerner Oral Surgery Course, KCI

PATIENT NAME: AGE:

CHIEF COMPLAINT:

Teeth to Extract:

3rd Molar Extraction:

Aveoloplasty 1-3 Teeth/Quad:

Aveoloplasty 4+ Teeth/Quad:

Intraoral Radiographic Findings:

Toras/Extosis/Frenectomy:

Approx Appt Time:

VITALS

BLOOD PRESSURE

SYSTOLIC

/

DIASTOLIC

PULSE RATE

PR

O2

OTHER CONSIDERATIONS

TREATMENT PLANNING

OTHER PROCEDURES RECOMMENDED

OTHER PROCEDURES

ALVEOPLASTY

INDICATE ALVEOPASTY TOOTH # BELOW

3 OR LESS MAXILLARY RIGHT

4 OR MORE MAXILLARY RIGHT

3 OR LESS MAXILLATY LEFT

4 OR MORE MAXILLARY LEFT

3 OR LESS MANDIBULAR RIGHT

4 OR MORE MANDIBULAR RIGHT

3 OR LESS MANDIBULAR LEFT

4 OR MORE MANDIBULAR LEFT

FRENECTOMY

WAS A FRENECTOMY PREFORMED?

YES

EPULIS

ADDITIONAL NOTES

INIDCATE THE PARTICPATING DENTIST WHO PREFORMED THE ABOVE PROCEDURES:

PRE-OPERATIVE MEDICAL SCREENING & PLANNING

Dr Koerner Oral Surgery Course, KCI

PATIENT NAME: AGE:

VITALS

BLOOD PRESSURE

PULSE RATE

O2

OTHER CONSIDERATIONS

TREATMENT PLANNING

ROUTINE EXTRACTIONS (2-15 & 18-31)

SURGICAL EXTRACTIONS (2-15 & 18-31)

3RD MOLAR 1, 16, 17, 32

OTHER PROCEDURES RECOMMENDED

ALVEOPLASTY

TORUS

EXOSTOSES

FRENECTOMY

EPULIS

BONE GRAFT

INDICATE LOCAL ANESTHETICS USED AMD HOW MANY CARTAGES:

ADDITIONAL NOTES