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    Dental Record Form CSPC

    Uploaded by

    JEREMY FOLLERO
    - The document is a dental record form from the Camarines Sur Polytechnic Colleges in the Philippines containing information about a patient's dental history and treatments. - It includes sections for the patient to acknowledge informed consent for their data to be collected and used for legitimate clinic purposes. - There are also sections to provide the patient's personal information, medical history, and dentition status which is filled out by the treating dentist. - The dentition status section acts as an ongoing record of the patient's dental treatments, noting things like fillings, extractions, and other remarks on their dates of service.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Dental Record Form CSPC

    Uploaded by

    JEREMY FOLLERO
    294 views2 pages
    - The document is a dental record form from the Camarines Sur Polytechnic Colleges in the Philippines containing information about a patient's dental history and treatments. - It includes sections for the patient to acknowledge informed consent for their data to be collected and used for legitimate clinic purposes. - There are also sections to provide the patient's personal information, medical history, and dentition status which is filled out by the treating dentist. - The dentition status section acts as an ongoing record of the patient's dental treatments, noting things like fillings, extractions, and other remarks on their dates of service.

    Original Title

    Dental Record Form CSPC (1)

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    - The document is a dental record form from the Camarines Sur Polytechnic Colleges in the Philippines containing information about a patient's dental history and treatments. - It includes sections for the patient to acknowledge informed consent for their data to be collected and used for legitimate clinic purposes. - There are also sections to provide the patient's personal information, medical history, and dentition status which is filled out by the treating dentist. - The dentition status section acts as an ongoing record of the patient's dental treatments, noting things like fillings, extractions, and other remarks on their dates of service.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    294 views2 pages

    Dental Record Form CSPC

    Uploaded by

    JEREMY FOLLERO
    - The document is a dental record form from the Camarines Sur Polytechnic Colleges in the Philippines containing information about a patient's dental history and treatments. - It includes sections for the patient to acknowledge informed consent for their data to be collected and used for legitimate clinic purposes. - There are also sections to provide the patient's personal information, medical history, and dentition status which is filled out by the treating dentist. - The dentition status section acts as an ongoing record of the patient's dental treatments, noting things like fillings, extractions, and other remarks on their dates of service.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    You are on page 1of 2

    Republic of the Philippines

    CAMARINES SUR POLYTECHNIC COLLEGES


    Student ID # __________________
    Nabua, Camarines Sur (c/o clinic staff)
    CSPC-F-DeN-01

    DENTAL RECORD
    DATA SUBJECT ACKNOWLEDGEMENT AND INFORMED CONSENT:
    “I hereby allow CSPC and its authorized personnel to collect and process the relevant data provided by me and consent to the
    confidential performance of legitimate clinic functions such as health assessment, examination, diagnosis, treatment, health
    evaluation, certification, emergency transfer, referral, reporting, validation, data security, and compliance to legal requirements. I
    also have been made aware of my data privacy rights to be informed, to object, to access, to rectification, to erasure / blocking, and
    right to damages and impact of such rights towards my medical & dental care.”

    __________________________________
    Signature Over Printed Name
    *For Data Privacy concerns, you may contact the CSPC Data Protection Officer at (054) 288-4421 (loc. 117).
    **for Clinic concerns you may call (054) 288-4421 (loc. 117) or text 0915-931-6811 (Globe), or 0951-932-3739 (Smart).

    PATIENT INFORMATION
    Name of Patient : ________________________________________________ Age: _________ Gender: _________
    Date of Birth : ________________________________________________ Marital Status: _________________
    Address : ________________________________________________ Course & Year: _________________

    In case of emergency, please notify:


    Name : _______________________________________________________ Telephone Number: _____________
    Address : ______________________________________________________________________________________

    Medical History: (Please check if you have any of the following conditions)
    _____ Hypertension _____ Diabetes _____ Heart Ailment
    _____ Epilepsy _____ Bleeding Disorder _____ Asthma
    _____ Lung Disease _____ Allergies _____ Tumor/Growth
    _____ Liver Disease _____ Kidney Disease _____ Others

    DENTITION STATUS

    (To be filled up by a Dentist)


    Remarks:

    Legend:
    DC- Dental Caries LC-Light Cure TF- Temporary Filling FB- FixedBridge
    AM-Amalgam Filling M-Missing due to Extraction RF-Root Fragment PT–Primary Tooth
    RD-Retained Deciduous RCT-Root Canal Tooth JC- Jacket Crown Un- Unerupted
    P -Pontic AB-Abutment X- For Extraction

    _______________________________
    Dentist
    _______________________________
    License Number

    Effectivity Date: January 2019 Rev.3 Page 1 of 2


    Republic of the Philippines
    CAMARINES SUR POLYTECHNIC COLLEGES
    Nabua, Camarines Sur
    CSPC-F-DeN-01

    Name: _________________________________________

    Date Treatment Remarks

    Effectivity Date: January 2019 Rev.3 Page 2 of 2

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