Clinical Photography Request Form

1
???????????? 3 ???????? ?????????????????? / If
there are more than 3 patients write their name
behind this paper
?????????????????????? Clinical Photography
Request Form
?????? / Date ....................................
..................................................
..................................................
............
??????????????? / Dentists name..................
....................??.???????? /
Curriculum...............
??????? / Department .............................
........
????????? / Patients name ??????????
/ The date photo taken.......................
CD ?????????????????? / CD Record name
..............
???????????????? / Date is use ..................
..................................................
.................................................
Note
???????????? 3 ???????? ?????????????????? / If
there are more than 3 patients write their name
behind this paper
?????????????????????? Clinical Photography
Request Form
?????? / Date ....................................
..................................................
..................................................
............
??????????????? / Dentists name.................
.....................??.???????? /
Curriculum................
??????? / Department ...........................
...........
????????? / Patients name ??????????
/ The date photo taken..........................
CD ?????????????????? / CD Record name
...............
???????????????? / Date is use ..................
..................................................
.................................................
???????? 1. ??.??????????????????????????????
???????????
1. Not allow to receive another person case.
Note
2.??????? CD ????????????????? 2 ???
2. Give CD in advance at least 2 day