false 26 Routing Slip RoutingSlip 10 Microsoft Sans Serif 850 1100 false 1 false false 1412 26 StaticText Subscriber: [subscriber2NameFL] Ins Co: [carrier2Name][ins2Employer] Annual Max: [ins2AnnualMax], Pending: [ins2Pending], Used: [ins2Used] Deductible: [ins2Deductible], Ded Used: [ins2DeductibleUsed] [ins2Percentages] 9 Microsoft Sans Serif false 448 685 365 125 None false 0 Left false -16777216 false 1411 26 StaticText 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] [insPercentages] Plan Notes: [insPlanNote] 9 Microsoft Sans Serif false 34 685 365 380 None false 0 Left false -16777216 false 1435 26 StaticText Needed Tx / Notes: 9 Microsoft Sans Serif false 451 960 365 75 DownLocal false 0 Left false -16777216 false 1410 26 StaticText Secondary Insurance 10 Microsoft Sans Serif true 443 662 370 17 None false 0 Center false -16777216 false 1408 26 StaticText Primary Insurance 10 Microsoft Sans Serif true 31 661 370 17 None false 0 Center false -16777216 false 1405 26 StaticText H: [HmPhone] W: [WkPhone] C: [WirelessPhone] E: [Email] R: [referredFrom] 9 Microsoft Sans Serif false 37 556 300 75 None false 0 Left false -16777216 false 1406 26 StaticText Allergies: [activeAllergies] Problems: [activeProblems] Current Medications:[currentMedications] 9 Microsoft Sans Serif false 53 68 750 85 None false 0 Left false -16777216 false 1404 26 StaticText [nameFL] [address] [cityStateZip] 9 Microsoft Sans Serif false 36 487 250 51 None false 0 Left false -16777216 false 1398 26 StaticText [nameFL] 10 Microsoft Sans Serif true 52 46 250 18 None false 0 Left false -16777216 false 1395 26 OutputText appt.timeDate 10 Microsoft Sans Serif true 341 46 250 18 None false 0 Left false 0 false 1392 26 OutputText appt.Note 9 Microsoft Sans Serif false 548 199 270 80 None false 0 Left false 0 false 1393 26 OutputText appt.procedures 9 Microsoft Sans Serif false 549 357 275 300 None false 0 Left false 0 false 1394 26 OutputText appt.providers 10 Microsoft Sans Serif true 612 46 200 18 DownLocal false 0 Left false 0 false 1413 26 StaticText Dental Encounter Sheet 11 Microsoft Sans Serif true 342 20 200 17 None false 0 Center false -16777216 false 1433 26 StaticText Patient Portion: __________________________ Total Treatment: ________________________ Discount: ______________________________ Pre-Payment: ___________________________ 9 Microsoft Sans Serif false 450 820 350 130 DownLocal false 0 Left false -16777216 false 1415 26 StaticText Guarantor: [guarantorNameFL] 9 Microsoft Sans Serif false 36 537 215 17 None false 0 Left false -16777216 false 1417 26 StaticText 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] 9 Microsoft Sans Serif false 345 519 200 120 None false 0 Left false -16777216 false 1418 26 StaticText Family Fin Note: [famFinUrgNote][famFinNote] 9 Microsoft Sans Serif false 294 444 250 65 DownLocal false 0 Left false -16777216 false 1420 26 StaticText Today 10 Microsoft Sans Serif true 580 157 195 18 None false 0 Center false -16777216 false 1434 26 StaticText Medical Hx Update? Yes No 9 Microsoft Sans Serif false 548 180 250 18 None false 0 Center false -16777216 false 1422 26 StaticText Incomplete Tx 10 Microsoft Sans Serif true 32 160 200 19 None false 0 Center false -16777216 false 1423 26 StaticText Critical Dates 10 Microsoft Sans Serif true 264 161 200 19 None false 0 Center false -16777216 false 1424 26 StaticText [treatmentPlanProcs] 9 Microsoft Sans Serif false 37 184 200 300 DownLocal false 0 Left false -16777216 false 1425 26 StaticText 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: [nextSchedApptsFam] 9 Microsoft Sans Serif false 262 187 275 250 None false 0 Left false -16777216 false 1426 26 StaticText Dental Encounter Sheett formatted by Bruce Stephenson, DDS / Today's Dental Consulting 209-603-9944 7 Verdana false 62 1055 700 12 None false 0 Center false -16777216 false 1427 26 StaticText Pre-Med? : [premedicateYN] 9 Microsoft Sans Serif false 549 279 225 16 None false 0 Left false -16777216 false 1428 26 StaticText Urgent Med Note: [MedUrgNote] 9 Microsoft Sans Serif false 549 301 270 55 None false 0 Left false -16777216