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 the form.
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. 2-26Continue Reading