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Your dental professional has just performed an oral cancer examination as part of your dental visit today. Our dental practice conforms to the standards set by the American Dental Association and the American Dental Hygienists’ Association that recognize this service as a critical element in disease prevention and health promotion that should be performed at routine dental visits. The results of this examination are being provided to you for your personal health record.
Head and neck examination:
____ No findings
____ Watch area for changes
____ Referral required
Oral examination:
____ No findings
____ Follow-up dental appointment required
____ Referral required
If the results of your examination are negative, we suggest that you continue to look at your own mouth using the checklist provided with the Oral Self-Exam Technique you have been shown and report any changes or suspicious areas to us for evaluation.
We emphasize the importance of returning for a follow-up visit to find out whether findings have improved, stayed the same, gone away or gotten worse, and if you need further treatment.
We will provide help with referrals and we stress the importance of completing the referral to find out what is causing the condition we found.
Thank you for allowing us to care for you.
Dr. ______________________________________________________________
Address: __________________________________________________________
Phone number: _____________________________________________________
Your Oral Cancer Examination form is presented to the patient at the time of an oral cancer examination.
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