GSA Form SF-603A Medical Record - Dental - Continuation

DD Form STANDARD603A or the "Health Record Dental - Continuation" is a Department of Defense-issued form used by and within the United States Army.

The form - often mistakenly referred to as the DA form STANDARD603A - was last revised on October 1, 1975. Download an up-to-date fillable PDF version of the DD STANDARD603A down below or find it on the Department of Defense documentation website.

ADVERTISEMENT
Standard Form 603-A
DENTAL
HEALTH RECORD
- Continuation
SECTION II. CHRONOLOGICAL RECORD OF DENTAL CARE
PAGE:
8. RESTORATIONS AND TREATMENTS (Completed during service)
9. SUBSEQUENT DISEASES AND ABNORMALITIES
REMARKS
REMARKS
10. SERVICES PROVIDED
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, PROVIDER, TREATMENT FACILITY (Sign each entry)
CLASS
PATIENT'S NAME (Last, First, Middle Initial)
SEX
PATIENT'S IDENTIFICATION (Use this Space for Mechanical
Imprint)
DATE OF BIRTH
RELATIONSHIP TO SPONSOR
COMPONENT STATUS
DEPART SERVICE
SPONSOR'S NAME
RANK/GRADE
SSN OR IDENTIFICATION NO.
ORGANIZATION
EXCEPTION TO SF 603A
Standard Form 603A (10-75)
APPROVED BY GSA/IRMS 1-91
GSA/ICMR
FIRMR (41 CFR) 201-45.505
Adobe Professional 8.0
Standard Form 603-A
DENTAL
HEALTH RECORD
- Continuation
SECTION II. CHRONOLOGICAL RECORD OF DENTAL CARE
PAGE:
8. RESTORATIONS AND TREATMENTS (Completed during service)
9. SUBSEQUENT DISEASES AND ABNORMALITIES
REMARKS
REMARKS
10. SERVICES PROVIDED
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, PROVIDER, TREATMENT FACILITY (Sign each entry)
CLASS
PATIENT'S NAME (Last, First, Middle Initial)
SEX
PATIENT'S IDENTIFICATION (Use this Space for Mechanical
Imprint)
DATE OF BIRTH
RELATIONSHIP TO SPONSOR
COMPONENT STATUS
DEPART SERVICE
SPONSOR'S NAME
RANK/GRADE
SSN OR IDENTIFICATION NO.
ORGANIZATION
EXCEPTION TO SF 603A
Standard Form 603A (10-75)
APPROVED BY GSA/IRMS 1-91
GSA/ICMR
FIRMR (41 CFR) 201-45.505
Adobe Professional 8.0
SECTION II. CHRONOLOGICAL RECORD OF DENTAL CARE
PAGE:
8. RESTORATIONS AND TREATMENTS (Completed during service)
9. SUBSEQUENT DISEASES AND ABNORMALITIES
REMARKS
REMARKS
10. SERVICES PROVIDED
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, PROVIDER, TREATMENT FACILITY (Sign each entry)
CLASS
PATIENT'S NAME:
SSN:
SF 603A (SIDE 2)
Reset

Download GSA Form SF-603A Medical Record - Dental - Continuation

1094 times
Rate
4.6(4.6 / 5) 65 votes
ADVERTISEMENT
Page of 2