ValueDent Plans

Patient ID Patient ID must contain only numbers

Patient Name

Age

Gender

Country

Date

Patient Notes

Hotel Name

Nights

3 Nights

5 Nights

6 Nights

Other Nights

Price Per Night

Apply Hotel To

1. Visit

2. Visit

Hotel Notes

Transportation Service

Required: No

Transportation Price

Apply Transportation To

1. Visit

2. Visit

Transportation Notes

1. Visit

Sinus Lift

Required: Not Required

Sinus Lift Types

Right Internal Sinus

Right External Sinus

Left Internal Sinus

Left External Sinus

Total Price: 0.00

Dental Chart

Treatment Selection

Tooth Problem

Treatment Type

Price

Discounted Price

Select Teeth

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

18

Tooth 18

Upper Right Third Molar

17

Tooth 17

Upper Right Second Molar

16

Tooth 16

Upper Right First Molar

15

Tooth 15

Upper Right Second Premolar

14

Tooth 14

Upper Right First Premolar

13

Tooth 13

Upper Right Canine

12

Tooth 12

Upper Right Lateral Incisor

11

Tooth 11

Upper Right Central Incisor

21

Tooth 21

Upper Left Central Incisor

22

Tooth 22

Upper Left Lateral Incisor

23

Tooth 23

Upper Left Canine

24

Tooth 24

Upper Left First Premolar

25

Tooth 25

Upper Left Second Premolar

26

Tooth 26

Upper Left First Molar

27

Tooth 27

Upper Left Second Molar

28

Tooth 28

Upper Left Third Molar

Tooth 48

48

Lower Right Third Molar

Tooth 47

47

Lower Right Second Molar

Tooth 46

46

Lower Right First Molar

Tooth 45

45

Lower Right Second Premolar

Tooth 44

44

Lower Right First Premolar

Tooth 43

43

Lower Right Canine

Tooth 42

42

Lower Right Lateral Incisor

Tooth 41

41

Lower Right Central Incisor

Tooth 31

31

Lower Left Central Incisor

Tooth 32

32

Lower Left Lateral Incisor

Tooth 33

33

Lower Left Canine

Tooth 34

34

Lower Left First Premolar

Tooth 35

35

Lower Left Second Premolar

Tooth 36

36

Lower Left First Molar

Tooth 37

37

Lower Left Second Molar

Tooth 38

38

Lower Left Third Molar

2. Visit

Enable 2. Visit: Not Active

2. Visit Dental Chart

2. Visit Treatment Selection

Tooth Problem

Treatment Type

Price

Discounted Price

Select Teeth

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

18

Tooth 18

Upper Right Third Molar

17

Tooth 17

Upper Right Second Molar

16

Tooth 16

Upper Right First Molar

15

Tooth 15

Upper Right Second Premolar

14

Tooth 14

Upper Right First Premolar

13

Tooth 13

Upper Right Canine

12

Tooth 12

Upper Right Lateral Incisor

11

Tooth 11

Upper Right Central Incisor

21

Tooth 21

Upper Left Central Incisor

22

Tooth 22

Upper Left Lateral Incisor

23

Tooth 23

Upper Left Canine

24

Tooth 24

Upper Left First Premolar

25

Tooth 25

Upper Left Second Premolar

26

Tooth 26

Upper Left First Molar

27

Tooth 27

Upper Left Second Molar

28

Tooth 28

Upper Left Third Molar

Tooth 48

48

Lower Right Third Molar

Tooth 47

47

Lower Right Second Molar

Tooth 46

46

Lower Right First Molar

Tooth 45

45

Lower Right Second Premolar

Tooth 44

44

Lower Right First Premolar

Tooth 43

43

Lower Right Canine

Tooth 42

42

Lower Right Lateral Incisor

Tooth 41

41

Lower Right Central Incisor

Tooth 31

31

Lower Left Central Incisor

Tooth 32

32

Lower Left Lateral Incisor

Tooth 33

33

Lower Left Canine

Tooth 34

34

Lower Left First Premolar

Tooth 35

35

Lower Left Second Premolar

Tooth 36

36

Lower Left First Molar

Tooth 37

37

Lower Left Second Molar

Tooth 38

38

Lower Left Third Molar

1. Visit Treatments

Tooth	Problem	Treatment	Price	Action
		Total:

2. Visit Treatments

Tooth	Problem	Treatment	Price	Action
		Total:

Cost Summary

Item	Price
1. Visit Dental Treatment	0.00
Hotel Accommodation	0.00
Transportation	0.00
Total	0.00

Select Currency:

Click to Merge with Template

Version 15.0.0