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CONSULTATION SHEET, SF 513 | Up
Dental Technican, Volume 2 - Dentist training manual for military dentists | Next
PATIENT DISMISSAL |
Figure 2-26.—Consultation Sheet, SF 513.
Date of Request: The date the Consultation
Sheet is prepared.
Reason for Request: The reason as stated by the
dentist or requester.
Provisional Diagnosis: The diagnosis as stated
by the dentist or requester.
Doctor's Signature: Type, print, or stamp the
name, rank, title of the dentist or requester with
his or her signature in this space.
Place of Consultation: Check "bedside" or "On
Call." Also mark the next box as "Routine,"
"Today," "72 Hours," or "Emergency."
Consultation Report: Leave blank. This
section will be filled in by the person receiving
the form.
Patient's Identification: The patient's name (last,
first, and middle initial), branch of service and
status, rank/rate, family prefix code, and social
security number, and the activity to which the
patient is assigned.
2-26
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