1) Sign‑in & Preparation

Arrival & Check-in

Time of arrival

Patient arrived on timePatient arrived earlyUnscheduled drop-inPatient arrived <10 minutes latePatient arrived >15 minutes lateProvider was <10 minutes lateProvider was >15 minutes late

Staff and Provider presented themselves

Pt identified?

Pt accompanied?

Tx or exam confirmed?

Medical History

MHR

Previous MHx and conditions

Allergy

Meds

Pre-op Meds started or stopped?

N.B. (Major Systemic issues)

noneHTNRespiratoryDMIDMIIPregnancy

N.B. (SUDs)

noneTobaccoCannabisAlcoholOther SUD

N.B. (Meds)

-***See List***ASAAnticoagulants (inc. DOAC)Bisphosphonates

Removable Appliances

Dentures/appliances (top)

N/ATop full dentureTop partial dentureimplant retainedTop NightguardRemovable orthodontic applianceFixed orthodontic appliance

Dentures/appliances (bottom)

N/ABottom full dentureBottom partial dentureimplant retainedBottom NightguardRemovable orthodontic applianceFixed orthodontic appliance

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1) Sign‑in & Preparation Arrival & Check-in Staff and Provider presented themselves: ? Pt identified?: ? Tx or exam confirmed?: ? Medical History MHR: No change Previous MHx and conditions: None declared Allergy: No known allergies Meds: None declared Pre-op Meds started or stopped?: N/A Removable Appliances Dentures/appliances (top): N/A Dentures/appliances (bottom): N/A Comments

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