DENTAL DENTAL CASE PRESENTATION CHECKLIST: DIAGNOSTIC RECORDS & TREATMENT OPTIONS

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--- DIAGNOSTIC RECORDS REVIEW ---
[ ] Date of Initial Exam
[ ] Patient's Age
[ ] Chief Complaint (Pain, Broken Tooth, Routine Checkup, Cosmetic Concerns, Other)
[ ] Summary of Patient History
[ ] Previous Records (if applicable)
[ ] Medical Allergies (None, Medications, Latex, Other)

--- RADIOGRAPHIC FINDINGS ---
[ ] Bitewing Exposure Factor
[ ] PA Exposure Factor
[ ] Radiographic Technique Quality (Excellent, Good, Fair, Poor)
[ ] Description of any pathology/abnormalities observed
[ ] Presence of Third Molars? (Yes, No, Not Visible)
[ ] Upload Radiographic Images (if needed for reference)

--- CLINICAL EXAMINATION FINDINGS ---
[ ] Bleeding on Probing (BOP) - Maxillary
[ ] Bleeding on Probing (BOP) - Mandibular
[ ] Occlusal Status (Normal, Mild Malocclusion, Moderate Malocclusion, Severe Malocclusion)
[ ] Detailed Notes on Soft Tissue Evaluation
[ ] Periodontal Pocket Depths (Average) (<3mm, 3-4mm, 4-6mm, >6mm)
[ ] Existing Restorations - Condition (Sound, Recurrent Decay, Fractured, Leaking)
[ ] Additional Clinical Observations

--- TREATMENT OPTIONS PRESENTED ---
[ ] Detailed Description of Treatment Option 1
[ ] Estimated Cost of Treatment Option 1
[ ] Treatment Option 1: Direct Access? (Yes, No)
[ ] Potential Risks and Complications of Treatment Option 1
[ ] Insurance Coverage for Treatment Option 1 (Estimated) (Fully Covered, Partially Covered, Not Covered)
[ ] Patient Questions/Concerns Regarding Treatment Option 1

--- PATIENT UNDERSTANDING & CONSENT ---
[ ] Summary of Treatment Plan Explained
[ ] Patient Acknowledges Risks and Benefits? (Yes, No)
[ ] Alternative Treatments Discussed? (Yes, No)
[ ] Estimated Treatment Cost
[ ] Date of Consent
[ ] Patient Signature
[ ] Witness Signature (if applicable)

--- FINANCIAL CONSIDERATIONS & PAYMENT PLAN ---
[ ] Estimated Total Treatment Cost
[ ] Patient's Estimated Insurance Coverage
[ ] Patient’s Financial Responsibility
[ ] Payment Options Offered (Cash, Check, Credit Card, Financing (e.g., CareCredit))
[ ] Financing Option Selected (if applicable) (None, CareCredit, Other (Specify in Long Text))
[ ] Specify Other Financing Option (if selected above)
[ ] Date Payment Plan Agreed Upon
[ ] Patient Signature - Acknowledgment of Payment Plan

--- DOCUMENTATION OF PRESENTATION ---
[ ] Summary of Patient's Understanding
[ ] Treatment Plan Accepted? (Yes, No, Pending Discussion)
[ ] Date of Presentation
[ ] Time of Presentation
[ ] Doctor Signature
[ ] Patient Signature (if applicable)

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