Transmittal Notice 67-65
The attached material is forwarded to replace those pages in Part 3, Chapter 2 of June 3, 1966 (TN No. 57) which were marked for later replacement by sample forms.
E.S. Rabeau, M.D.
Assistant Surgeon General
Director, Division of Indian Health
Part 3, Chapter 2, Appendix II:
Page 14a, Sample Form PHS-2056-1, Patient Epidemiology and Service Record
Pages 18a & 18b, Sample Form PHS-2964, Authorization for and Report of Contract Dental Care
Page 21a, Sample Form PHS-2506-2, Page 1, Dental Epidemiology and Service Report
Page 21b, Sample Form PHS-2506-2, Page 2, Master Mark Form 12
Page 26a, Sample Form PHS-2506-3, Page 1, Orthodontic Examination and Report
Page 26b, Sample Form PHS-2506-3, Page 2, Master Mark Form 13
Page 35a & 35b, Sample Form PHS-2506-4, Interceptive Orthodontic Register Record.
"Marker" pages for the above material.
Substitute the attached pages for the superseded ones. Discard the superseded pages.
Distribution: P-ABCDG under d, B, C under d
Date: January 3, 1967
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