Acknowledgment of Surveillance Camera Installation
Notice, acknowledgement/release and policy to inform patients and staff that surveillance cameras are in use
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
Authorization for Caretaker to Accompany a Minor
Sample authorization for a non-legal guardian to accompany a minor patient to dental appointments
Authorization for Release of Dental Records
Form for a patient to authorize release of records to another dentist, physician or authorized representative
Caregiver's Authorization Affidavit
Form for a caregiver to authorize a minor’s participation in school-related care or other medical care
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
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