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POLI GIGI

KLNIK CIPTA MEDIKA


JL. RAYA TEBING TINGGI KM 2.5 KOMPLEK PT.LONTAR

No. Rekam Medis


FORMULIR PEMERIKSAAN ODONTOGRAM

NAMA :
UMUR :
JENIS KELAMIN :
ALAMAT :

TMJ : .........................................................................
Tonsil : .........................................................................
Bibir : .........................................................................
Lidah : .........................................................................
Palatum : .........................................................................
Diastema : .........................................................................
Gusi : .........................................................................
Mukosa mulut : .........................................................................
Lain-lain : .........................................................................

Ro foto : ....................................................................... Tanggal : ..........................................................

Gambaran Radiografis : .............................................................................................................................

Gigi Status Klinis Diagnosa Treatment Planning

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