Tooth chart - Wa



|[pic] |DATE |

| |      |

| | |

|Tooth Chart | |

| |CLIENT’S NAME |

| |      |

| |CLIENT’S ID NUMBER |

| |      |

|DENTIST/DENTURIST’S NAME |DENTIST/DENTURIST’S PHONE NUMBER (with Area Code) |

|      |      |

|PROVIDER NPI NUMBER |PROVIDER FAX NUMBER |

|      |      |

|Have all dental and periodontal services been completed on all remaining teeth? Yes ____ No ____ |

|If not, please submit treatment plan and periodontal chart. |

|Mark the chart below |

|[pic] |

HCA 13-863 (2/15)

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