LEFTRIGHT

18

48

47

46

45

44

4342

41 3132

33

34

35

36

37

38

17

16

15

14

1312 11 21 22

23

24

25

26

27

28

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Clinical

Impression:_________________________________________________________________________

Mucosal Examination ChartPatient name:Case Number:Exam Date:Clinician:

Form A - Upper/Lower Arch

LIP

LIP

© 2007 LED Dental Inc. 01-08-07

LEFTRIGHT

48

47

46

45

4443

4241 31

3233

34

35

36

37

38

Mucosal Examination ChartPatient name:Case Number:Exam Date:Clinician:

Form B: Tongue-Lateral View

Form C: Tongue Underside

48 47 46 45 44RIGHT LEFT

43 42 41 31 32 33 34 35 36 37 38

www.velscope.com

Clinical

Impression:_________________________________________________________________________

LIP

© 2007 LED Dental Inc. 01-08-07