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Subscriber: [subscriber2NameFL]
Ins Co: [carrier2Name][ins2Employer]
Annual Max: [ins2AnnualMax], Pending: [ins2Pending], Used: [ins2Used]
Deductible: [ins2Deductible], Ded Used: [ins2DeductibleUsed]
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Subscriber: [subscriberNameFL]
Ins Co: [carrierName]
Fee Schedule: [insFeeSchedule]
Type: [insType]
Employer: [insEmployer] Unused Ben: [insRemaining] ([insPending] pending)
Deductible: [insDeductible], Ded Used: [insDeductibleUsed]
Freq.: EX-[insFreqExams], BW-[insFreqBW], Pano-[insFreqPanoFMX]
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Plan Notes: [insPlanNote]
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Needed Tx / Notes:
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Secondary Insurance
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Primary Insurance
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H: [HmPhone]
W: [WkPhone]
C: [WirelessPhone]
E: [Email]
R: [referredFrom]
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Allergies: [activeAllergies]
Problems: [activeProblems]
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[nameFL]
[address]
[cityStateZip]
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[nameFL]
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appt.Note
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Dental Encounter Sheet
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Patient Portion: __________________________
Total Treatment: ________________________
Discount: ______________________________
Pre-Payment: ___________________________
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Guarantor: [guarantorNameFL]
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0-30:[bal_0_30]
31-60:[bal_31_60]
61-90:[bal_61_90]
90+:[balOver90]Balance
Current:[balTotal]
-Ins Est: [balInsEst]
=Pat.Total: [balTotalMinusInsEst]
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Family Fin Note: [famFinUrgNote][famFinNote]
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Today
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Medical Hx Update? Yes No
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Incomplete Tx
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Critical Dates
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[treatmentPlanProcs]
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DOB: [Birthdate] [age]
Next Appt: [nextSchedApptDateT]
Last Appt: [dateTimeLastAppt]
Last Pano: [dateLastPanoFMX] Due? [dueForPanoYN]
Last BW: [dateLastBW] Due? [dueForBWYN]
Last Exam: [dateLastExam]
Recall Interval: [recallInterval]
Recall Due Date: [dateRecallDue]
Family Appointments:
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Dental Encounter Sheett formatted by Bruce Stephenson, DDS / Today's Dental Consulting 209-603-9944
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Pre-Med? : [premedicateYN]
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Urgent Med Note: [MedUrgNote]
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