15DC2770_Clinical Forms_173-196 2/13/15 11:06 AM Page 176 CLINICAL FORMS Exam & Record Forms Back Back Front Front GEOMETRIC EXAM RECORD FORM EXAM/ACCOUNT RECORD FORM * Front has tooth charts as shown, with an area for clinical data and medical/dental history summaries * Back has space for necessary services and their fees * 81/2" x 11" horizontal (367-9820) ................................................................250 per Pkg. 2 Pkg.@ 4 Pkg.@ * Front of this 2-sided form features "1-32" numbering, "a-t" lettering, and an area to summarize patient history * Back side has space to list services needed or rendered and fees * Printed on sturdy ledger stock * 81/2" x 101/2" horizontal (367-3430) ................................................................250 per Pkg. 35.99 2 Pkg.@ 33.99 4 Pkg.@ 30.99 (367-9762) Opaque Stock 35.99 33.99 30.99 Front (367-5533) Index Stock CLINICAL PATIENT CHART * Letter-size chart allows for plenty of space to record comprehensive, permanent patient records * 2-sided form includes room for clinical findings, patient histories, and charge information, among others * Printed with green ink on 80 Lb. offset opaque stock or heavy-duty, 110 Lb. index card stock * 81/2"W x 11"H 80-Lb. Opaque Stock.................................................100 per Pkg. 2 Pkg.@ 5 Pkg.@ 21.79 20.79 18.79 110 Lb. Index Card Stock ..........................................100 per Pkg. 2 Pkg.@ 5 Pkg.@ Specify: 25.99 24.99 22.99 Specify: (367-9762) (367-3554) (367-5533) (367-6663) 176 www.henryscheindental.com Back Back (367-3554) Opaque Stock (367-6663) Index Stock Fronthttp://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3679820%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3673430%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3679762%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675533%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3679762%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3673554%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3673554%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3676663%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675533%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3676663%26CatalogName%3DDENTAL http://www.henryscheindental.com