20 19 • 18 17 21 Ito Occlusion: Oral Hygiene: Good Pair Poor CP:TN 3 2- Flead 8 Neck / Soft Tissue: C M: F: Classification: CL___ Pain Scaie: /1O Dental Prostheses at Intake: Yes No Type: Age: Condition: Comm cx i n _it, ..?.. P rl g i Rcess I Or) Db 1.4.,—,ter &Nicol car aW

No: Oral Hygiene: CPITN: Gocd Far Poor 3 3 2- 3 Head & Neck / Soft Tissue: D: M: I F: p 146 of 148 (b)(6): Classification: CLr Pain Scaie: PIO nt to exempt-was.' Tan 09 )(AR/ /115 /1.1"-r2 R SS ‘,G2 21/2 SUU-2- • of the Freedom of Int rr itoye And c2r z.„Aic y t ay. cayoLiA 0.