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Tooth
Tooth
Ben R Johnson DMD
Given to Patient
Emailed to
Mailed PA or PANO
Date Taken
Implants please mark tooth areas on the chart below
ezPRO
Tissue Former
INOL
Fixture Level
Intraoral Scan
Tooth Extractions please mark tooth areas on the chart below
Oral Biopsy/Pathology
Trauma/Injury
Other/Comments Remarks or Special Instructions
Primary Tooth
H. Sean Moon DDS MD
Sohaib H Soliman DDS
Kevin Huang, DDS, MD
Michael Baily, DMD
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