Form 26 - Indirect Restorative Procedure Outline

Indirect Restorative Procedure Outline

Patient Information¹

• Use Patient Barcode Label
• Given Name:
• Surname:
• DOB:
• TEMP:

Clinician Details

• Clinician Signature:
• Clinician ID:
• Date:
• Procedure:

Patient and Clinician Identification

Diagram

Procedure Description

Clinical Procedure Documentation

Clinical Stages and Authorisation

Clinical Stages²

Each stage requires date, signature, and clinical code (2 signatures required).

1. DISCUSSION (design, abutments and mounting needs)
2. FORM 26 signed – CC:
3. SP TRAYS and FINAL IMPRESSION
4. MMR
5. TRY IN
6. INSERTION

Authorisation

• Procedure Outline Authorised by:
• Clinician ID:
• Date:

Footnotes

1. Original PDF page 1: Form 26 - Indirect Restorative Procedure Outline, p.1 ↩

2. Original PDF page 2: Form 26 - Indirect Restorative Procedure Outline, p.2 ↩