RIGHT SIDE OF FOLDER
Form Number
Form Title and Notes
DA Form 4515
Personnel Reliability Program Record Identifier (see AR
50-5).
*SF 603/603A
Health Record--Dental File. (Health Record--Dental
(Continuation)) when needed as a continuation of
Section III (A ttendance Record) of SF 603.
DA Form 3984
Dental Treatment Plan.
SF 513
Medical Record--Consultation Sheet.
SF 519B
Radiologic Consultation Request/Report.
SF 522
Medical Record--Request for Administration of
Anesthesia and for Performance of Operations and other
Procedures.
*DA Form 4410-R
Disclosure Accounting Record (to be included if DD
Form 722-1 is used as the folder instead of the DA Form
3444-series).
*DD Form 2005
Privacy Act Statement--Health Care Records (to be
include d if DD Form 7221- is used as the folder instead
of the DA Form 3444-series (see para 1-6c, AR 40-2)).
LEFT SIDE OF FOLDER
Form Number
Form Title and Notes
DA Form 5570
Health Questionnaire For Dental Treatment.
*
Panographic X-ray made during reception station
processing (later X-rays may be kept in the record).
*
Other local use.
* This form must be included in all dental records.
Table 2-2. Forms and documents of the Dental Record.
MD0751
2-9