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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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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

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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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Authorization for Release of Dental Records

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

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Caregiver's Authorization Affidavit

Form for a caregiver to authorize a minor’s participation in school-related care or other medical care

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

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Updated

Consent to Disclose Personal Health Information (PHI)

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

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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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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