When to use this fluoride and sealant template

Use it for visits where you apply fluoride varnish (D1206) or other topical fluoride (D1208), place sealants (D1351, billed per tooth), or both. These are quick procedures, so their notes tend to be one line, but payers often limit them by age, frequency, and tooth. A note that names the risk, the product, and each tooth gives the claim what it needs.

What to record

Caries risk and the factors behind it. This is the reason for the treatment.
The fluoride product and concentration, plus the instructions given.
Every tooth sealed, by number, with the surfaces.
Isolation and etch, since moisture control decides whether a sealant lasts.
The retention and occlusion check at the end.

Example note

Patient seen for preventive treatment; parent/guardian consented. Caries risk moderate; risk factors: deep pits and fissures, frequent sugar intake. Fluoride: 5% sodium fluoride varnish (D1206) applied to all erupted tooth surfaces; soft foods and no hot drinks for 4–6 hours. Sealants placed (D1351) on #3, #14, #19, and #30, occlusal surfaces. Pumice prophy; cotton rolls and dry angles; phosphoric acid etch, frosty enamel confirmed; resin-based sealant, light-cured. Retention verified with explorer, occlusion checked. Check sealants at every recall.