Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines (Page 2 of 4) in pdf

Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines Page 2

Appendix A

Patient Name: _______________________________

Does the client currently have/or is wearing:

Upper Full Denture

Lower Full Denture

Yes

If YES date of insertion:

dd/mm/yy

If YES date of insertion:

dd/mm/yy

Upper Cast Partial

Lower Cast Partial

Yes

If YES date of insertion:

dd/mm/yy

If YES date of insertion:

dd/mm/yy

Upper Acrylic Partial

Lower Acrylic Partial

Yes

If YES date of insertion:

dd/mm/yy

If YES date of insertion:

dd/mm/yy

Section C: Oral Health Status:

Periodontal Condition:

Poor

Acceptable

Good

Bone Structure:

Poor

Acceptable

Good

Mobility of remaining teeth:

None

Slight

Moderate

Severe

Caries present

Yes

Especially in any supporting teeth

Oral Hygiene:

Poor

Acceptable

Good

NOTES:

A completed estimate indicating procedure codes, fees and patient’s signature must be

submitted with the clinical notes/chart, along with a copy of the patient’s current dental

card (Ontario Works or ODSP).

For partial dentures, there must be one or more missing teeth in the anterior sextant OR

excluding

there must be two or more missing posterior teeth in EACH quadrant,

the

second and third molars

If posterior teeth have been missing for more than three (3) years, indicate rationale for

replacing these teeth at this time.

Please complete the entire chart on the last page (teeth missing, teeth to be extracted,

restorations required)

Please note that all outstanding dental conditions must be remedied prior to insertion of

denture/partial.

Created Date: June 2013

Revision Date: October 2013

Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines Page 2

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