Acknowledgment of Surveillance Camera Installation
Notice, acknowledgement/release and policy to inform patients and staff that surveillance cameras are in use
Authorization for Release of Dental Records
Form for a patient to authorize release of records to another dentist, physician or authorized representative
CBCT Scan Form Set
Full set of CBCT sample forms, including informed consent, refusal, referral and notice of non-read scan
Consent to Disclose Personal Health Information (PHI)
Form and recommendations for obtaining consent to disclose patient health information to a third party.
Consultation for Dental Treatment
Form for a mutual patient’s physician to confirm medical condition, diagnosis and/or fitness for treatment
Dental History
Form for capturing a patient’s at-home oral hygiene, dental concerns and treatment history
Diagnostic X-rays Required Letter
Sample letter to inform and educate a patient of necessary X-rays to continue dental treatment
Dispensing Products Acknowledgment
Form to document products that are dispensed to a patient (does not apply to medications)
Emergency Phone Screening to Determine Appointment Immediacy
Form to facilitate patient screening by phone and determine immediacy, appointment need or emergency care
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