Name of Child

Date:

m

m

d

d

y

y

Dx:

Purpose                            Type

1  001  Medical               1  01  Routine (Comprehensive)

1  002  Dental                 1  002  Follow-Up (Problem Specific)

Rx:

                                          1  003  Other (Sick or Emergency)

If routine is medical, is follow-up needed:

Provider Signature:

                                          1  001  Yes         1  002  No

Name:

If Yes, describe:

Address:

E N C O U N T E R   F O R M

Name of Child

Date:

m

m

d

d

y

y

Dx:

Purpose                            Type

1  001 Medical                1  001  Routine (Comprehensive)

1  002 Dental                  1  002  Follow-Up (Problem Specific)

Rx:

                                          1  003  Other (Sick or Emergency)

If routine is medical, is follow-up needed:

Provider Signature:

                                          1  001 Yes          1  002  No

Name:

If Yes, describe:

Address: