15DC2770_Clinical Forms_173-196 2/13/15 10:31 AM Page 177 Exam & Record Forms CLINICAL FORMS Back Front CLINICAL PATIENT CHART FORM PERIODONTAL STATUS FORM * Comprehensive 1-sided form includes space to record clinical indicators * 2-hole punch at top * Printed with green ink * 81/2"W x 11"H (367-3559) ................................................................100 per Pkg. 19.79 2 Pkg.@ 18.79 5 Pkg.@ 16.79 * 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 110 Lb. index stock * Made from 20% postconsumer recycled content * 81/2"W x 11"H 80 Lb. Opaque Stock (367-5094) ................................................................100 per Pkg. 21.79 2 Pkg.@ 20.79 5 Pkg.@ 18.79 110-Lb. Index Stock (367-4052) ................................................................100 per Pkg. 25.99 2 Pkg.@ 24.99 5 Pkg.@ 22.99 Back-Page 4 Inside-Page 3 Inside-Page 2 DENTAL RECORD FORM * 4-page medical/dental record * Detailed form captures all of your important clinical findings * Designed with space for clinical findings, patient histories, estimates, charting, charge information, and progress notes * Printed on offset opaque stock * 17"W x 11"H overall size, folds to 81/2"W x 11"H (367-1164)...................................................................50 per Pkg. 19.79 2 Pkg.@ 18.79 5 Pkg.@ 16.79 Imprinted Materials: 800.414.0940 8am-4:30pm (ET) Front-Page 1 Call To Order: 800.372.4346 8am-9pm (ET) 177http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675094%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3674052%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3673559%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671164%26CatalogName%3DDENTAL