Patient:

Datum:

Time:

Start planing (picture and draw from)

Time:

Start local anesthesia, doner area

Time:

Start extraction, doner area

Time:

Start local anesthesia, recipient area

Time:

Start channel, recipient area

Time:

Start implanting grafts

Time:

Finish grafts planting

Time:

Patient leaves room

Number of grafts total:

Singel:

Dubbel:

Triple:

Quadruple:

Local anesthesia:

Ml:

Xylocaine Dental, 20mg / 12,5 Microgram/ml

Ml:

Xylocaine Adrenalin, 10mg / 5 microgram

Ml:

Marcin, 5mg/ml

Ml:

Adrenalin, 1mg/ml NaCl Solution

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