ALL CARE DENTAL CENTRE - 1

#198,Above Hotel New Shanthi sagar

CMH Road,Indiranagar,Bangalore-560 038.

Prof: Dr.A.Jayakumar.

Phone No: 25256789

BDS,MDS.(Orthodontist).

ALL SPECIALITIES

Dr.M.J.Murali.

MONDAY TO SATURDAY:

BDS,MDS.(Endodontist & cosmetic dentist).

9.30 A.M to 1 P.M

Dr.M.J.Venkatesh

4.30 P.M to 8 P.M

BDS,MDS.(Orthodontist).
__________________________________________________________________________________________________

Name: Jagadish.A

Date:

Age:31 yrs.

Address: House.No.5

Sex:M

Phone:9611044292

Anjaneya temple street,ulsoor.

Bangalore.

Chief complaints:

1. h/o old composite

filling on Tooth#14. Pain on hard chewing.

2. caries in tooth#30
X-Ray:

Treatment plann:

For 14 & 30.

Scaling,complete

dental cleaning.

RCT 14.
RCT 30.

Consent: I Mr.

__Jagadish.A _______________ . the undersigned give my consent for any suitable dental treatment

Including surgeries to be performed on me.

I have been explained the procedures & risks involved in the language understood by me and thereby undertake
Responsibilities for any consequences that may arise therefrom.

Signature of Patient/ Guardian.

Diagnosis:
Treatment plan:
Consent:
I Mr./Mrs.________________________________________________________ the undersigned give my consent for any
suitable dental treatment including surgeries to be performed on me/my son/ward
Master/Miss ______________________________________________________ under any anaesthesia deemed necessary .
I have been explained the procedures & risks involved in the language understood by me and therby undertake responsibilities
for any consequences that may arise therefrom.

Signature of Parent/Guardian/Parent.

Date

Treatment

Charge

RCT 14

Rs. 7,000

RCT 30

Rs. 7,000

SCALING & COMPLETE DENTAL CLEANING

Rs. 3,000

_____________________________________________________________________________________________________
TOTAL:

Rs. 17,000

_____________________________________________________________________________________________________