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Form - Pit & Fissure Sealant Completion Log

Pit & Fissure Sealant Completion Log

Please add the student name in the form below exactly as it appears on your ID

Student First Name

Student Last Name

Written Exam Score: (must be 75% or higher)

How many patients

1

2

3

4

Patient’s Full Name

Date

Teeth sealed #

Student Initial

Patient’s Full Name

Patient’s Full Name

Date

Date

Teeth sealed #

Teeth sealed #

Student Initial

Student Initial

Patient’s Full Name

Patient’s Full Name

Patient’s Full Name

Date

Date

Date

Teeth sealed #

Teeth sealed #

Teeth sealed #

Student Initial

Student Initial

Student Initial

Patient’s Full Name

Patient’s Full Name

Patient’s Full Name

Patient’s Full Name

Date

Date

Date

Date

Teeth sealed #

Teeth sealed #

Teeth sealed #

Teeth sealed #

Student Initial

Student Initial

Student Initial

Student Initial

Patient name

Patient name

Patient name

Patient name

Patient name

Date

Date

Date

Date

Date

Teeth sealed #

Teeth sealed #

Teeth sealed #

Teeth sealed #

Teeth sealed #

Student Initial

Student Initial

Student Initial

Student Initial

Student Initial