Standard Form 603a, Health Record Dental - Continuation
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1
2Standard Form 603-A
DENTAL
HEALTH RECORD
- Continuation
SECTION II. CHRONOLOGICAL RECORD OF DENTAL CARE
PAGE:
8. RESTORATIONS AND TREATMENTS (Completed during service)
9. SUBSEQUENT DISEASES AND ABNORMALITIES
REMARKS
REMARKS
10. SERVICES PROVIDED
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, PROVIDER, TREATMENT FACILITY (Sign each entry)
CLASS
PATIENT'S NAME (Last, First, Middle Initial)
SEX
PATIENT'S IDENTIFICATION (Use this Space for Mechanical
Imprint)
DATE OF BIRTH
RELATIONSHIP TO SPONSOR
COMPONENT STATUS
DEPART SERVICE
SPONSOR'S NAME
RANK/GRADE
SSN OR IDENTIFICATION NO.
ORGANIZATION
EXCEPTION TO SF 603A
Standard Form 603A (10-75)
APPROVED BY GSA/IRMS 1-91
GSA/ICMR
FIRMR (41 CFR) 201-45.505
Adobe Professional 8.0
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Parent category: Medical