DENTAL APPOINTMENT CHECKLIST: TREATMENT PLANNING & RECALL

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--- PATIENT ARRIVAL & INITIAL ASSESSMENT ---
[ ] Appointment Date
[ ] Appointment Time
[ ] Patient Name
[ ] Patient Age
[ ] Chief Complaint / Reason for Visit
[ ] Medical History Update Required? (Yes, No)
[ ] Blood Pressure (Systolic)
[ ] Blood Pressure (Diastolic)
[ ] Temperature Taken? (Yes, No)

--- TREATMENT PLANNING REVIEW ---
[ ] Summary of Patient Concerns/Chief Complaint
[ ] Review of Previous Treatment/History
[ ] Explanation of Proposed Treatment Plan
[ ] Estimated Treatment Cost
[ ] Patient Understanding of Treatment Plan? (Yes, No, Partially)
[ ] Informed Consent Obtained? (Yes, No)
[ ] Date of Consent/Discussion
[ ] Patient Questions/Concerns Addressed

--- CLINICAL PROCEDURES CHECKLIST ---
[ ] Vital Signs - Blood Pressure (mmHg)
[ ] Vital Signs - Heart Rate (bpm)
[ ] Local Anesthesia Administered? (Yes, No)
[ ] Anesthesia Notes (if applicable)
[ ] Suction Used? (Yes, No)
[ ] Instruments Used (Check all that apply) (Handpiece, Explorer, Scaler, Curette, Elevator, Composite Filling, Amalgam Filling)
[ ] Procedure Notes

--- RADIOGRAPHY & DOCUMENTATION ---
[ ] FVDI (Fluoride Vial Dose Indicator) Reading
[ ] Radiograph Type (PA, BW, Pano, CBCT) (Periapical (PA), Bitewing (BW), Panoramic (Pano), Cone Beam CT (CBCT))
[ ] Exposure Settings (kVp)
[ ] Exposure Settings (mA)
[ ] Exposure Time (Seconds)
[ ] Radiographic Findings (Detailed Description)
[ ] Digital Radiograph Image(s)
[ ] Image Quality Assessment (Excellent, Good, Acceptable, Needs Repeat)

--- RECALL APPOINTMENT SCHEDULING ---
[ ] Next Recall Appointment Date
[ ] Preferred Recall Time (optional)
[ ] Number of Months Until Next Recall
[ ] Recall Method (Phone Call, Text Message, Email, Postal Mail)
[ ] Notes Regarding Recall Preferences
[ ] Patient Confirmation Status (Confirmed, Rescheduled, Cancelled)

--- FINANCIAL DISCUSSION & AUTHORIZATION ---
[ ] Estimated Total Treatment Cost
[ ] Patient's Estimated Insurance Coverage
[ ] Patient's Estimated Out-of-Pocket Cost
[ ] Payment Plan Options Discussed (No Payment Plan, CareCredit, In-House Payment Plan, Other (Specify))
[ ] Notes on Financial Discussion
[ ] Authorization Form Signed? (Yes, No)
[ ] Insurance Card Copy (Optional)
[ ] Patient Signature (Financial Acknowledgment)

--- PATIENT EDUCATION & DISCHARGE ---
[ ] Post-Treatment Instructions Provided (Oral Hygiene, Diet, Pain Management)
[ ] Did patient express understanding of instructions? (Yes, No, Unsure)
[ ] Patient Concerns/Questions Addressed
[ ] Follow-Up Appointment in (Days)
[ ] Scheduled Follow-Up Appointment Date
[ ] Method of Recall Confirmation (Phone, Mail, Email, Text Message)
[ ] Recall Confirmation Notes

--- CHART DOCUMENTATION & BILLING ---
[ ] Total Treatment Cost
[ ] Patient Co-pay
[ ] Insurance Portion Paid
[ ] Billing Status (Not Billed, Submitted, Paid, Rejected)
[ ] Date of Billing Submission
[ ] Billing Notes/Comments
[ ] Insurance Claim Form (if applicable)
[ ] Payment Method (Cash, Check, Credit Card, Insurance)

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