Figure 2-26.Consultation Sheet, SF 513.
Date of Request: The date the Consultation
Sheet is prepared.
Reason for Request: The reason as stated by the
dentist or requester.
Provisional Diagnosis: The diagnosis as stated
by the dentist or requester.
Doctor's Signature: Type, print, or stamp the
name, rank, title of the dentist or requester with
his or her signature in this space.
Place of Consultation: Check "bedside" or "On
Call." Also mark the next box as "Routine,"
"Today," "72 Hours," or "Emergency."
Consultation Report: Leave blank. This
section will be filled in by the person receiving
Patient's Identification: The patient's name (last,
first, and middle initial), branch of service and
status, rank/rate, family prefix code, and social
security number, and the activity to which the
patient is assigned.