Treatment Plan Form

Patient*

Doctor/Assistant*

Room #*

Chart #*

ATTN*

Oral Cance/TMJ*

Present Condition

Treatment Plan

Fee

1*

1*

1*

2*

2*

2*

3*

3*

3*

4A*

4A*

4A*

5B*

5B*

5B*

6C*

6C*

6C*

7D*

7D*

7D*

8E*

8E*

8E*

9F*

9F*

9F*

10G*

10G*

10G*

11H*

11H*

11H*

12I*

12I*

12I*

13J*

13J*

13J*

14*

14*

14*

15*

15*

15*

16*

16*

16*

17*

17*

17*

18*

18*

18*

19*

19*

19*

20K*

20K*

20K*

21L*

21L*

21L*

22M*

22M*

22M*

23N*

23N*

23N*

24O*

24O*

24O*

25P*

25P*

25P*

26Q*

26Q*

26Q*

2R7*

27R*

27R*

28S*

28S*

28S*

29T*

29T*

29T*

30*

30*

30*

31*

31*

31*

32*

32*

32*

Perio Type

Occlusal Exam Class

Occlusal Exam Class Type

Ortho YesNo

Nightguard YesNo

Notes*