The encounter form is to be completed for each patient seen.

  1. Completion of services is indicated in one of five ways:
    • Circle the letter “C” (completed) next to the appropriate code;
    • Identify the number of films taken for Additional Periapical films;
    • Note the tooth code – number (1 – 32) and letter (A – T) – for all surgical procedures, all endodontic, procedures, all sealants, and such restorative procedures as stainless steel crowns, labial veneers, and resin crowns;
    • Note the tooth code and surface code for all amalgam and composite restorations;
    • Circle the quadrant scaled for periodontal scalings.
  2. Services in progress are indicated by circling the letter “P” to the left of the service code. Services without a “P” indicate that the service is completed in one visit. Services in progress include the fitting of bands for a space maintainer, post-operative visits for surgical procedures, and endodontic visits prior to the filling of the root canal.
  3. The category OTHER SERVICES is to be used for those procedures not listed on the encounter form and should be completed as listed above.
  4. THE DENTAL PROVIDER – DENTIST AND HYGIENIST – MUST SIGN FORM AT THE BOTTOM OF THE PAGE AND INDICATE THE PROFESSIONAL DEGREE.