Initial Clinical Examination

Record keeping for general soft tissue findings

The Initial Clinical Examination form is used to record general "soft tissue" findings. It is easy to complete with a question and answer technique between assistant and the doctor. The patient hears the examination. Once completed, this form may be photocopied for insurance documentation.

The lower quarter of the form is designed to track case acceptance, referral and basic informed consent for periodontal treatment. This section may be completed during the patient's treatment conference or at a subsequent appointment.

The Periodontal Screening (C-203R) and/or the Comprehensive Periodontal Examination (C-103R), the Initial Data Base and Recommendations (C-102R) and the Initial Clinical Examination (C-104R) complete the new patient examination process.

  • Perio tissues and home care screening
  • Cancer screening
  • Occlusal evaluation
  • Radiographic findings and treatment classification
  • Documents informed consent and informed refusal
  • Detailed referral tracking
  • Specifies responsibility for supportive periodontal treatment
C-104R Initial Clinical Examination
$18.00 / 200 $34.00 / 400
$64.00 / 800 $120.00 / 1600



To preview
Sample Form in PDF format


If you are having
trouble viewing 
the samples 







Privacy Policy