Checklists and Forms for the New Patient Exam

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New Patient Exam Study Packet- This packet of forms and checklists should be printed and used when studying the New Patient Exam Course.

New Patient Orthodontic Exam Form Page 1- This is the Patient Information and Medical and Dental History data form for the New Patient Exam. The practice logo may be added to the top of the form.

New Patient Orthodontic Exam Form Page 2- This is the exam findings section of the New Patient Exam form. This form allows the patient to be examined in "Planes of Space."

NPE-01 New Patient Exam Checklist- This checklist summarizes all of the steps the New Patient Coordinator should perform when assisting in the New Patient Exam. It is also a good review of the exam findings that all orthodontic clinical assistants should know when treating patients.

New Patient Call Intake Script and Intake Form- This script and form should be followed when a new patient calls to schedule a New Patient Exam.

 MS Word Document

New Patient Call Intake Intake Form Only- This two-sided form should be printed on both sides and then cut in half for two forms. It should be completed when a new patient calls and schedules a New Patient Exam. After the exam, the form should be kept in a system of follow-up if the patient did not schedule records.

MS Word Document

NPE Welcome Letter Summary of Findings- This is a sample summary letter that may be completed and given to the new patient after the exam. It is designed to clearly outline the concerns that are identified and the recommended treatment. It should be sent home with a copy of the initial photographs that were taken at the exam. The practice logo can be placed at the top of the form.

MS Word Document

Payment Options Template- This Excel spreadsheet is usefull to give to the new patient at the conclusion of the exam that summarizes the findings, treatment recommendations, and fee options for the patient.

 MS Excel Spreadsheet

Records Are Needed- This form summarizes the records that are needed and the fees charged in 2003 for those records. This form may be edited to fit the needs of the practice.

MS Word Document

Time To Start Treatment Summary- This form is similar to the NPE Welcome Letter but is intended for Recall/Observation patients who are ready to begin. It may be edited to fit the practice.

MS Word Document

Fee Schedule Template- This Excel Spreadsheet lists all possible orthodontic procedures for which a fee will be charged to the patient. Insert the fees of the practice for quick reference when quoting fees.

MS Excel Spreadsheet

Acrobat Reader - To download, view and print the PDF Checklists you need to have Adobe Acrobat Reader Installed.