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PDF Dental Certificate Compress
PDF Dental Certificate Compress
DEPARTMENT OF EDUCATION
Region
Division
Latest 1½ x 1½ picture
Name:
Age: Sex Birth Date Date
Event:
Parent/Guardian: GINGIVITIS
Coach: PERIODONTAL
DISEASE
CONDITION AND TREATMENT NEEDS MALOCCLUSION
CONDITION SUPERNUMERAR
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Y TOOTH
TEMPORARY TEETH
RETAINED
DECIDOUS
DECUBITAL ULCER
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 CALCULUS
CLEFT PALATE
PERMANENT TEETH
ROOT FRAGMENT
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 FLUOROSIS
CONDITION
OTHERS (Specify)
TREATMENT NEEDS
TEMPORARY TEETH
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:
DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined: