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
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 October 23, 2015 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 June 30, 2016 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 October 23, 2015 Sample Forms Alaska Arizona California Hawaii Illinois Minnesota Nevada New Jersey North Dakota Oregon Pennsylvania Washington Documentation General Liability
Caregiver's Authorization Affidavit Form for a caregiver to authorize a minor’s participation in school-related care or other medical care October 23, 2015 Sample Forms California 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
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
Consultation for Dental Treatment Form for a mutual patient’s physician to confirm medical condition, diagnosis and/or fitness for treatment October 23, 2015 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 October 23, 2015 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 October 23, 2015 Sample Forms Alaska Arizona California Hawaii Idaho Illinois Minnesota Montana Nevada New Jersey North Dakota Oregon Pennsylvania Tennessee Washington Documentation General Liability Patient Care