**QA1 HEALTHCENTRE**
**OF WESTERN AUSTRALIA**
**Form 26**
**Indirect Restorative**
**Procedure Outline**
**Use Patient Barcode Label**
Given Name
Surname
DOB
TEMP
Clinician Signature:
**Clinician ID:**
**Date:**
**Procedure:**
**Diagram**
**Procedure description:**
Form 26_Version 1/2012_page 1 of 2
### Patient Information
- Use Patient Barcode Label
- Given Name:
- Surname:
- DOB:
- TEMP:
### Clinician Details
- Clinician Signature:
- Clinician ID:
- Date:
- Procedure:
### Diagram
### Procedure Description
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A header section displaying 'Form 26 Indirect Restorative Procedure Outline'.
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A form field section containing headers 'Use Patient Barcode Label', 'Given Name', 'Surname', 'DOB', and 'TEMP' with corresponding blank lines.
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A signature block table containing fields for 'Clinician Signature', 'Clinician ID', and 'Date'. A row below is labeled 'Procedure'.
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A dental diagram illustrating two arches of teeth: one representing the lower jaw (mandible) and one the upper jaw (maxilla). The teeth are drawn in outline with internal markings indicating restorations or specific points of interest on each tooth.
**Form 26 Indirect Restorative Procedure Outline continuation**
**Stage** Date, Signature and clinical code (2 signatures required)
**DISCUSSION (design, abutments and mounting needs)**
**FORM 26 signed** CC:
**SP TRAYS and FINAL IMPRESSION**
**MMR**
**TRY IN**
**INSERTION**
Procedure Outline Authorised by:
Clinician ID:
Date:
Form 26 Version 12/12 page 2 of 2
#### Clinical Stages
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:
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Table titled 'Stage' and 'Date, Signature and clinical code (2 signatures required)'. The table lists stages of an indirect restorative procedure: DISCUSSION (design, abutments and mounting needs), FORM 26 signed, SP TRAYS and FINAL IMPRESSION, MMR, TRY IN, INSERTION. A CC column is included.
[^1]: Original PDF page 1: [[Form 26 - Indirect Restorative Procedure Outline.pdf#page=1|Form 26 - Indirect Restorative Procedure Outline, p.1]]
[^2]: Original PDF page 2: [[Form 26 - Indirect Restorative Procedure Outline.pdf#page=2|Form 26 - Indirect Restorative Procedure Outline, p.2]]