The Dentists Insurance Company (TDIC)

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Acknowledgment of Surveillance Camera Installation

Notice, acknowledgement/release and policy to inform patients and staff that surveillance cameras are in use

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Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Pennsylvania Documentation General Liability

Authorization for Caretaker to Accompany a Minor

Sample authorization for a non-legal guardian to accompany a minor patient to dental appointments

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Sample Forms State Alaska Arizona California Hawaii Illinois Nevada New Jersey North Dakota Pennsylvania Documentation General Liability Patient Care

Authorization for Release of Dental Records

Form for a patient to authorize release of records to another dentist, physician or authorized representative

Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Oregon Pennsylvania Washington Documentation General Liability

CBCT Scan Form Set

Full set of CBCT sample forms, including informed consent, refusal, referral and notice of non-read scan

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Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Pennsylvania Documentation General Liability Patient Care

Consent to Disclose Personal Health Information (PHI)

Form and recommendations for obtaining consent to disclose patient health information to a third party.

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

Consultation for Dental Treatment

Form for a mutual patient’s physician to confirm medical condition, diagnosis and/or fitness for treatment

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Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care

Dental History

Form for capturing a patient’s at-home oral hygiene, dental concerns and treatment history

Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation Patient Care

Diagnostic X-rays Required Letter

Sample letter to inform and educate a patient of necessary X-rays to continue dental treatment

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Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care

Dispensing Products Acknowledgment

Form to document products that are dispensed to a patient (does not apply to medications)

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Sample Forms State Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington General Liability Patient Care

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Dr. Rebecca Irene Pena

Service is always amazing. I really appreciate TDIC, and I feel they value me, my practice and our relationship.

Dr. Kristen Stewart

TDIC agents are enthusiastic and willing to solve my problems or answer my questions quickly and efficiently. That’s what I like about TDIC.

Dr. Camtam Nguyen