Consent to Disclose Personal Health Information (PHI) Form and recommendations for obtaining consent to disclose patient health information to a third party. July 12, 2024 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Premises Incident Report Form for documenting injuries involving patients or visitors inside or outside the practice May 03, 2024 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability
Office Closure Checklist A checklist to help minimize property damage, secure the premise and protect assets during a closure April 12, 2024 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington General Liability
Dispensing Products Acknowledgment Form to document products that are dispensed to a patient (does not apply to medications) November 23, 2022 Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington General Liability Patient Care
Acknowledgment of Surveillance Camera Installation Notice, acknowledgement/release and policy to inform patients and staff that surveillance cameras are in use March 03, 2020 Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Pennsylvania Documentation General Liability
Swallowed or Aspirated Object Letter Sample letter to a patient regarding the discussion of and next steps for a swallowed or aspirated object October 24, 2018 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada North Dakota Oregon Pennsylvania Tennessee Washington General Liability Patient Care
Sensory Recording Chart Sample chart for recording a neurological examination, including symptoms and clinical findings July 12, 2018 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care
Authorization for Caretaker to Accompany a Minor Sample authorization for a non-legal guardian to accompany a minor patient to dental appointments June 30, 2016 Sample Forms State Alaska Arizona California Hawaii Illinois Nevada New Jersey North Dakota Pennsylvania Documentation General Liability Patient Care
CBCT Scan Form Set Full set of CBCT sample forms, including informed consent, refusal, referral and notice of non-read scan June 22, 2016 Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Pennsylvania Documentation General Liability Patient Care
Self-Sufficient Minor Form certifying and documenting the self-sufficient minor status for diagnosis or treatment October 23, 2015 Sample Forms Arizona California Washington Documentation General Liability Patient Care