Patient Sign-Out

Patient Sign-Out

Patient Name

Treatments Suggested

Notes for Sign-Out

Schedule an In-Home Service:

Yes

No

Click All In-Home Services to be Scheduled:

Household Exams

SRP

Ortho

How many exams will be scheduled?

How many SRPs will be scheduled?

How many Orthos will be scheduled?

Do they have the same insurance plan?

Yes

No

Approx Appt Time Needed

In-Home Date