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Patient Information
Patient Name
Date of Visit
Reason for Visit
Attending Physician
Oral Hygiene Assessment
Plaque Level
Calculus Level
Gingival Inflammation
Bleeding on Probing
Recession
Mobility
Furcation Involvement
Treatment Provided
Scaling
Root Planing
Fluoride Treatment
Oral Hygiene Instruction
Additional Comments
Patient Education
Homecare Recommendations
Patient Compliance
Patient Understanding
Next Appointment