SHINDE`S DENTAL CLINIC

Dr. Sandip Shinde Reg. No.

B.D.S.(Dental surgeon) Mo. 7721859191

PATIENT RECORD CARD

Name: Date: .
Age: Sex: Mo: .
Address: Case Paper No: .
History
Medical: .
Dental: .
allergies to any drug: .

INFORMED CONSENT
I Mr./Mrs. / Ms. Give
informed consent to Dr. Sandip Shinde for any such treatment to me/my ward as may
be required in the interest of me / my wards Oral & Dental health and under any
anesthesia deemed suitable if required for the procedure.
I understand that necessary information will be given to me from time to
time on every proposed treatment procedure and I have been explained about limitation
& consequences of the procedures.
I agree to pay the fees for above treatment procedures and will abide by it.
I give consent for any change in anesthesia / treatment plan as deemed necessary by the
doctor at the time of medication / investigation / procedure / therapy.

Signature of Patient/ Patient's Guardian

Date: Time:
ससससस सससस
सस ससससस सससस ससससस सससस / सससस
सस , सससससससस / सससससस ससससससससससस ससससससस
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ससससस ससससससस सससससससस ससस ,ससस ससससससससससससस
ससससससससस ससससस सस ससस सससससससस ससससससस ससस सससस
सससससससस सससससससस ससससससस सससससससस सससससस सससस
सससस ,सस सससससससससस सससससससस ससससससस ससससस सससस.
सससससससससस सससससससससससस ससससस ससससससस / सससस ससस
ससससस सससस .
सससस ससससससससस ससससससससससससस ससससससस
सससससससससससस ससससस ससससससससससस सस ससस ससससस ससससस
सस सससससस ससससस सससससस
ससस सससससससससस सससस सससस सस ससस ससससस ससस .
ससससस / ससससससससस
ससससससससससस ससस
सससससस :
ससस :

Chief Complaint: .
 Tretment Plan:
RCT: .
Filling: .
Extraction: .
Any Other: .
.

Date Treatment Done Payment Done Balance