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Does the patient require antibiotics prior to treatment
Frenectomy
Ridge Augmentation
Hard Tissue
Being Mailed
Please Take
Given to Patient
200
1
2
14
3
4
5
6
7
8
9
10
11
12
13
15
16
a
b
c
d
e
f
g
h
i
j
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
k
l
m
n
o
p
q
r
s
t
Extraction see chart above
Expose and Bond
PreProsthetic
Alveoplasty
Soft Tissue
Cleft Lip and Palate
Biopsy
Cosmetic
Incision and Drainage
Apicoectomy
Exposure
TMJ
OralFacial Lesion
Implants
Bone Grafting
Infection
Orthognathic Evaluation
Other
Attached
No Xray
x

Additional Signatures Required