 Dental Forms Library
The NNOHA Dental Forms Library is a collection of forms in use by safety-net oral health programs across the country. These sites are sharing their forms to allow other programs to have a reference in developing their own material. These forms have not undergone legal reviews through NNOHA and it is assumed that each site will take the necessary precautions to assure thay are provided accurate information based on the requirements of their own state and organiation. If you do not see a form that you are looking for, feel free to contact info@nnoha.org, or if you are a NNOHA member, we encourage you to post your request in the NNOHA Forums.
The following resources require Adobe Acrobat to view.
To download a free copy of Adobe Acrobat, click here.
I. Consent Forms:
English: Authorization for Anesthesia; Dental Hygiene; Endodontic Treatment; Extraction of Teeth 1; Extraction of Teeth 2; General Consent; Nitrous Oxide; Parental Consent; Patient Mgmt Techniques; Pediatric Dentistry; Perform Dentistry; Photos/Video Tapes Release; Post-Op for Extractions; Root Canal; Special Procedures Consent; Treatment by Extern Dentist; Treatment by Student; Consent for Safety Steps (Pediatric Dentistry)
Spanish: Anestesia; Cirujia Oral; Endodoncia; Extraccion; General Consent; Oxido Nitroso; Procedimientos Especiales; Tratamiento Dental
II. Refusal Forms: X-Ray Refusal; Informed Refusal Form; Informed Refusal for X-Ray and Dental Treatment; Refusal of Recommended Treatment
III. Excuse Letters: Excuse Letter
IV. Consultation Requests: Consultation Request; Medical Consultation Request
V. Policies & Procedures:
Financial:
English: Clinic Audit Forms, Fee Estimate; Financial Policy; Payer Types; The Superbill
Spanish: Reglamentos Financieros
Emergencies: Dental Emergencies; Emergencies; Fire Safety; Medical Emergencies; Pain/Trauma
Records: Records Management
Miscellaneous:
English: Appointment Cancel/Reschedule; Child's Appointment; Dental Clinic Policies; Dental Radiology; General Information; Medical Referrals; Parents In Treatment Rooms; Patient Management Techniques; Patient Rights & Responsibilities; Policy; Performance Appraisals; Professional Nuggets; ALARA Program; Encounter Form 2; Fingernail guidelines; Safety Steps Policy (Pediatric Dentistry)
Spanish: Cancelada; Informacion Referente; Necessitamos; Poliza
VI. Patient Information:
English: Encounter Form; Health History Form; Initial Patient Contact; Medical History Form; Patient Info Sheet;
Spanish: Historia de Salud; Initial Patient Contact
VII. Guidelines & Instructions:
English: Care after Extraction; Extraction Precautions; Instructions for Patients Who Receive IV Sedation; Local Anesthesia; Oral Surgery Instruction; Procedure Form; Discharging a Patient
Spanish: Extracion Precausiones; Instucciones Cirujia
VIII. New Provider Information:
CHC History/Facilities/Services/Programs/Staff; Credentialing Requirements; Credentials Package; Health Status Questions; Privilege Request Form; Release of Information for Professional Competence/Training; Welcome to CHC Clinic
IX. Education Materials:
For Patients:
English: Baby's Mouth; Care for Teeth; Diabetes/English; Diabetes/Oral Health 1; Diabetes/Oral Health 2; Facts on Diabetes; Mouth Cancer; Patient Emergencies; Plaque & Tartar; Pregnancy/Oral Health; Dentures and Partials; Diabetes and Your Teeth, Oral Cancer; Patient Etiquette, Periodontal Disease; Pregnancy and Oral Health; Preterm LBW Babies; Root Canal; Tooth Removal
Spanish: Baby's Mouth; Dentures and Partials; Diabetes and Your Teeth, Oral Cancer; Patient Etiquette, Periodontal Disease; Pregnancy and Oral Health; Preterm LBW Babies; Root Canal; Tooth Removal
English/Spanish: Pediatric Dental Advice
Russian: Baby's Mouth; Dentures and Partials; Diabetes and Your Teeth, Oral Cancer; Patient Etiquette, Periodontal Disease; Pregnancy and Oral Health; Preterm LBW Babies; Root Canal; Tooth Removal
French: Baby's Mouth; Dentures and Partials; Diabetes and Your Teeth, Oral Cancer; Patient Etiquette, Periodontal Disease; Pregnancy and Oral Health; Preterm LBW Babies; Root Canal; Tooth Removal
For Providers:
Acetaminophen; Dental Access; Dental Issues; Dental Progs; Diabetes; Oral Health; Pediatric Dosing; Pregnant Patient; Incident Form
X. Human Resources Forms:
LIP Documents Check List (1); LIP Documents Check List (2); HR Credentialing Checklist; Credential Committe Letter; Staff Evaluation Form; Monthly Bonus Plan; Executive Director Evaluation Form; Executive Director Performance Appraisal (NACHC); Front Desk Orientation Procedure; Sample Interview Questions (Dentist); Provider Peer Review
Job Descriptions:
Please note that the position descriptions provided through NACHC and NNOHA are generic in nature. These templates offer a basis from which specific, detailed, and more legally compliant position descriptions can be further modified to reflect your individualized needs.
Dental Director (Word | PDF); Dentist (Word | PDF); Dental Hygienist (Word | PDF); Dental Assistant (Word | PDF)
XI. Miscellaneous:
Dental Equipment Maintenance Log; Levin Group Order Form; OSHA Material Safety Data Sheet; US Army Pregnancy and Postpartum Training; Social Networking Policy
Dental first aid [flipchart]
http://www.cdphe.state.co.us/pp/oralhealth/EmergencyDentalFlipChart.pdf
Produced by the Colorado Department of Public Health and
Environment, Oral Health Program
Dental first aid for children [flipchart]
http://www.fha.state.md.us/oralhealth
Produced by the Maryland Department of Health and Mental Hygiene
Dental first aid
Click here to download the archived webpage
Produced by the Kansas Department of Health and Environment,
Oral Health Initiative
Emergency guidelines for schools. (3rd ed.) [guidelines]
http://www.schoolhealth.org/content/emerGuide.pdf
Produced by the Ohio Department of Health, School and
Adolescent Health, School Nursing Program
XII. Quality Assurance/Quality Improvement
Clinical Information Systems; CommunityResources; Decision Support Example1; Decision Support Example2; Delivery System Design Example; Dental Navigation Sheet Example; Oral Health Self Management Goals; Organization ofHealthcareA; Organization ofHealthcareB; Organization ofHealthcareC; PDSA Dental Navigation; Quality Improvement_HRSA Requirements
NNOHA does not guarantee the accuracy or completeness of forms or links contained within this Web site, and accepts no liability for the content of this library or for any and all consequences resulting from the use of these forms or links or from any actions taken on the basis of the information provided. Any provider using these forms or links assumes all risk associated with their use.
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