Dental Appointment Checklist: Treatment Planning & Recall

Patient Arrival & Initial Assessment

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Tasks to complete upon patient arrival and before treatment begins, including vital signs and initial concerns.

Appointment Date

Appointment Time

Patient Name

Patient Age

Chief Complaint / Reason for Visit

Medical History Update Required?

Yes

Blood Pressure (Systolic)

Blood Pressure (Diastolic)

Temperature Taken?

Yes

Treatment Planning Review

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Ensuring the treatment plan is reviewed, understood, and accepted by the patient.

Summary of Patient Concerns/Chief Complaint

Review of Previous Treatment/History

Explanation of Proposed Treatment Plan

Estimated Treatment Cost

Patient Understanding of Treatment Plan?

Yes

Partially

Informed Consent Obtained?

Yes

Date of Consent/Discussion

Patient Questions/Concerns Addressed

Clinical Procedures Checklist

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Step-by-step checklist for specific dental procedures performed during the appointment.

Vital Signs - Blood Pressure (mmHg)

Vital Signs - Heart Rate (bpm)

Local Anesthesia Administered?

Yes

Anesthesia Notes (if applicable)

Suction Used?

Yes

Instruments Used (Check all that apply)

Handpiece

Explorer

Scaler

Curette

Elevator

Composite Filling

Amalgam Filling

Procedure Notes

Radiography & Documentation

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Ensuring proper radiographic techniques, processing, and documentation are followed.

FVDI (Fluoride Vial Dose Indicator) Reading

Radiograph Type (PA, BW, Pano, CBCT)

Periapical (PA)

Bitewing (BW)

Panoramic (Pano)

Cone Beam CT (CBCT)

Exposure Settings (kVp)

Exposure Settings (mA)

Exposure Time (Seconds)

Radiographic Findings (Detailed Description)

Digital Radiograph Image(s)

Image Quality Assessment

Excellent

Good

Acceptable

Needs Repeat

Recall Appointment Scheduling

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Scheduling appropriate follow-up appointments and confirming patient understanding of recall frequency.

Next Recall Appointment Date

Preferred Recall Time (optional)

Number of Months Until Next Recall

Recall Method

Phone Call

Text Message

Postal Mail

Notes Regarding Recall Preferences

Patient Confirmation Status

Confirmed

Rescheduled

Cancelled

Financial Discussion & Authorization

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Reviewing treatment costs, insurance coverage, and obtaining necessary authorizations.

Estimated Total Treatment Cost

Patient's Estimated Insurance Coverage

Patient's Estimated Out-of-Pocket Cost

Payment Plan Options Discussed

No Payment Plan

CareCredit

In-House Payment Plan

Other (Specify)

Notes on Financial Discussion

Authorization Form Signed?

Yes

Insurance Card Copy (Optional)

Patient Signature (Financial Acknowledgment)

Patient Education & Discharge

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Providing post-treatment instructions, answering questions, and ensuring patient understanding.

Post-Treatment Instructions Provided (Oral Hygiene, Diet, Pain Management)

Did patient express understanding of instructions?

Yes

Unsure

Patient Concerns/Questions Addressed

Follow-Up Appointment in (Days)

Scheduled Follow-Up Appointment Date

Method of Recall Confirmation

Phone

Mail