Transcript Accident report Augusta Family Dentistry

Augusta Family Dentistry, P.A.
401 State St
Augusta, KS 67010
Accident report
Dr. Paul Mitsch & Dr. Rob Colt
316-775-2482
Name of patient: ________________________ DOB:_________________
Day of the accident:_____________________ Time:_________________
Place of the accident:___________________________________________
Date of the evaluation:____________
Referred to:____________________
Assistant:_______________________
Type and nature of the injury: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Surgical treatment necessary:
Radiographs taken:
Periapical Intraoral
Tooth
number
Panoramic Film
Type
Cephalometric Study
Submentovertex
AP Town
Computerized Tomogram
TMJ
Series
Paranasal
Implant
Sinus Series
Series
Restorative treatment necessary
Tooth number
Type
Medications prescribed: _____________________
___________________
_____________________
___________________
Version III
2009
Doctor’s Report
Initial Status:
Date:
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Status:
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Status
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Version III
2009