Sample Forms

We’re here to make record keeping easier and more efficient so you can better protect your practice. View, download and customize the right resources for your state. Find sample forms and letters to support documentation, employment, general liability and patient care.

Search Sample Forms

Select a StateSelect a TopicSort Results

Search

Acknowledgment of Surveillance Camera Installation

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

Download form

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

Authorization for Agent to Consent to Dental Treatment of a Minor

Sample treatment authorization for an adult to whom care of a minor has been entrusted

Sample Forms Alaska Arizona California New Jersey Pennsylvania 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

Download form

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

Download form

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

Download form

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

Download form

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

Download Tip

Some browsers will provide an option to save the file to your computer/device, others will automatically download the file to your downloads/files folder.

The Risk Management Advice Line is always helpful!

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

Explore More Resources

Access a dentistry-focused risk management articles, guides, sample letters, informed consent forms and more.

Explore tools and guidance