15DC2770_Clinical Forms_173-196 2/13/15 10:32 AM Page 185 Consent & Aftercare Forms CLINICAL FORMS 1. Endodontic Treatment 2. Extractions 3. Surgical Extractions CONSENT FORMS * Help your patients to understand the reasons for and benefits of certain treatments * Confirm their intent for treatment with their signature, and retain a copy for your records * Choose from 2 different formats: 2-part carbonless, or bond paper * Color choices available on bond paper only * Sizes: 2-Part: 81⁄2"W x 11"H, Bond: 81⁄2"W x 11"H Item # 1. 367-1007 367-1008 2. 367-1004 367-1005 3. 367-1019 367-1020 4. 367-1010 367-1011 Description Endodontic Treatment Endodontic Treatment Extractions Extractions Surgical Extractions Surgical Extractions Restorations Restorations Format 2-Part Bond 2-Part Bond 2-Part Bond 2-Part Bond Lines 5 5 5 5 5 5 5 5 Price $42.49 $31.29 $42.49 $31.29 $42.49 $31.29 $42.49 $31.29 3@ $30.29 $20.49 $30.29 $20.49 $30.29 $20.49 $30.29 $20.49 5@ $29.29 $19.49 $29.29 $19.49 $29.29 $19.49 $29.29 $19.49 4. Restorations 1 Step Blue (B) Step Choose PAPER* White (W) Canary (C) Green (G) Buff (Bu) Pink (P) *Bond Paper Items Only 2 Choose TYPESTYLE Step 3 Choose LOGO 3000 3080 Imprinted Materials: 800.414.0940 8am-4:30pm (ET) 3001 3081 3002 3087 3003 3004 3005 3083 319 8166 Call To Order: 800.372.4346 8am-9pm (ET) 185http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671007%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671008%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671004%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671005%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671019%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671020%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671010%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3671011%26CatalogName%3DDENTAL