AF IMT Form 1418 Recommendation for Flying or Special Operational Duty - Dental

AF IMT Form 1418 or the "Recommendation For Flying Or Special Operational Duty - Dental" is a form issued by the U.S. Air Force IMT (Information Management Tool).

Download a PDF version of the AF IMT Form 1418 down below or find it on the U.S. Air Force IMT (Information Management Tool) Forms website.

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RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY - DENTAL
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use blanket PAS - DD Form 2005)
TO:
FROM:
DATE/TIME OF TREATMENT
NAME (Last, First, Middle Initial)
GRADE
SSN
ORGANIZATION
DIAGNOSIS
TREATMENT
MEDICATION ADMINISTERED
MEDICATION PRESCRIBED
Local anesthesia:
YES
NO
Other:
RECOMMEND NO PARTICIPATION IN FLYING OR SPECIAL OPERATIONAL DUTY FOR
HOURS OR
DAYS.
PATIENT TO RETURN TO CLINIC FOR FOLLOW-UP EVALUATION ON
.
RECOMMEND RETURN TO FLYING OR SPECIAL OPERATIONAL DUTY.
FSO NOTIFIED BY PHONE.
TYPED OR PRINTED NAME AND GRADE OF DENTAL OFFICER
SIGNATURE
DATE
I CERTIFY that i understand the above recommendation.
SIGNATURE OF PATIENT
DATE
AF IMT 1418, 20171213, V2
PREVIOUS EDITIONS ARE OBSOLETE.
Copy 1 - Flight Medicine via Member
RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY - DENTAL
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use blanket PAS - DD Form 2005)
TO:
FROM:
DATE/TIME OF TREATMENT
NAME (Last, First, Middle Initial)
GRADE
SSN
ORGANIZATION
DIAGNOSIS
TREATMENT
MEDICATION ADMINISTERED
MEDICATION PRESCRIBED
Local anesthesia:
YES
NO
Other:
RECOMMEND NO PARTICIPATION IN FLYING OR SPECIAL OPERATIONAL DUTY FOR
HOURS OR
DAYS.
PATIENT TO RETURN TO CLINIC FOR FOLLOW-UP EVALUATION ON
.
RECOMMEND RETURN TO FLYING OR SPECIAL OPERATIONAL DUTY.
FSO NOTIFIED BY PHONE.
TYPED OR PRINTED NAME AND GRADE OF DENTAL OFFICER
SIGNATURE
DATE
I CERTIFY that i understand the above recommendation.
SIGNATURE OF PATIENT
DATE
AF IMT 1418, 20171213, V2
PREVIOUS EDITIONS ARE OBSOLETE.
Copy 1 - Flight Medicine via Member
RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY - DENTAL
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use blanket PAS - DD Form 2005)
TO:
FROM:
DATE/TIME OF TREATMENT
NAME (Last, First, Middle Initial)
GRADE
SSN
ORGANIZATION
DIAGNOSIS
TREATMENT
MEDICATION ADMINISTERED
MEDICATION PRESCRIBED
Local anesthesia:
YES
NO
Other:
RECOMMEND NO PARTICIPATION IN FLYING OR SPECIAL OPERATIONAL DUTY FOR
HOURS OR
DAYS.
PATIENT TO RETURN TO CLINIC FOR FOLLOW-UP EVALUATION ON
.
RECOMMEND RETURN TO FLYING OR SPECIAL OPERATIONAL DUTY.
FSO NOTIFIED BY PHONE.
TYPED OR PRINTED NAME AND GRADE OF DENTAL OFFICER
SIGNATURE
DATE
I CERTIFY that i understand the above recommendation.
SIGNATURE OF PATIENT
DATE
AF IMT 1418, 20171213, V2
PREVIOUS EDITIONS ARE OBSOLETE.
Copy 2 - Flight Medicine via Member
RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY - DENTAL
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use blanket PAS - DD Form 2005)
TO:
FROM:
DATE/TIME OF TREATMENT
NAME (Last, First, Middle Initial)
GRADE
SSN
ORGANIZATION
DIAGNOSIS
TREATMENT
MEDICATION ADMINISTERED
MEDICATION PRESCRIBED
Local anesthesia:
YES
NO
Other:
RECOMMEND NO PARTICIPATION IN FLYING OR SPECIAL OPERATIONAL DUTY FOR
HOURS OR
DAYS.
PATIENT TO RETURN TO CLINIC FOR FOLLOW-UP EVALUATION ON
.
RECOMMEND RETURN TO FLYING OR SPECIAL OPERATIONAL DUTY.
FSO NOTIFIED BY PHONE.
TYPED OR PRINTED NAME AND GRADE OF DENTAL OFFICER
SIGNATURE
DATE
I CERTIFY that i understand the above recommendation.
SIGNATURE OF PATIENT
DATE
AF IMT 1418, 20171213, V2
PREVIOUS EDITIONS ARE OBSOLETE.
Copy 3 - Flight Medicine via Member

Download AF IMT Form 1418 Recommendation for Flying or Special Operational Duty - Dental

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