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DIA

MES

AO

HISTORIA CLINICA DE ODONTOLOGA


NOMBRE DEL PACIENTE: ________________________________________________________
I.D: ____________________________________ Email: _________________________________________________
EDAD: ____ FECHA NACIMIENTO: ___________________ OCUPACIN: ________________________________
Tel. CASA: __________________ Tel. TRABAJO_____________________ Cel: ______________________________
DIRECCION CASA: _______________________________________________________________________________

MOTIVO DE CONSULTA: __________________________________________________________________________


ANTECEDENTES MEDICOS Y ODONTOLOGICOS: ____________________________________________________
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DIAGNSTICO: __________________________________________________________________________________
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OBSERVACIONES:_______________________________________________________________________________
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PRESUPUESTO DEL TRATAMIENTO


PACIENTE: _________________________________________ ID: ______________________________

FECHA

PROCEDIMIENTO

VALOR

EVOLUCION DEL TRATAMIENTO

FECHA

PACIENTE: _________________________________________ ID: ____________________________

PROCEDIMIENTO

ABONO

SALDO

FIRMA

FIRMA

ODONTOLOGO

PACIENTE