DCSooner
1/31/2006, 04:56 PM
Not to see one, but for them to fill this out for me::eek:
This is to verify that ________________________ received a dental examination on _____________. To the best of my professional ability, based on visual examination and appropriate diagnostic tests, I certify that it is unlikely that this individual will need urgent or emergent dental care in the next 6-12 months. I understand that the reason for this certification is that he/she will be deployed to an area of the world where dentists may not be available and that demobilization back to the United States may be necessary for proper treatment.
Office Name_________________________________ Date________________________
Address___________________________________________ ___________________
Phone Number____________________________________________ _____________
Dr. Name __________________________________________________ ___________________
Dr. Signature_________________________________________ __________________
Patient Signature__________________________________ SS# _________________
This is to verify that ________________________ received a dental examination on _____________. To the best of my professional ability, based on visual examination and appropriate diagnostic tests, I certify that it is unlikely that this individual will need urgent or emergent dental care in the next 6-12 months. I understand that the reason for this certification is that he/she will be deployed to an area of the world where dentists may not be available and that demobilization back to the United States may be necessary for proper treatment.
Office Name_________________________________ Date________________________
Address___________________________________________ ___________________
Phone Number____________________________________________ _____________
Dr. Name __________________________________________________ ___________________
Dr. Signature_________________________________________ __________________
Patient Signature__________________________________ SS# _________________