Dental Program Management

Dental Forms Library

These forms were shared with NNOHA from safety-net clinics throughout the country for use in your dental program. Browse the forms in five different categories:


Consent Forms

Denture Treatment
Endodontic Treatment
Endodontic Treatment 2
Endodontic Treatment 3 – English and Spanish
Extraction of Teeth 1
Extraction of Teeth 2
Extraction of Teeth 3
Extraction of Teeth – Spanish
General Consent
General Consent – Spanish
Nitrous Oxide Consent – English and Spanish
Oral Surgery Consent – English and Spanish
Pediatric: Consent for Dental Treatment
Pediatric: Consent for Safety Steps
Pediatric: Patient Management Techniques
Pediatric: Restraint Consent – English and Spanish
Photo or Video Release Consent Form – Adult (English and Spanish)
Photo or Video Release Consent Form – Child (English and Spanish)
Refusal of Treatment 1
Refusal of Treatment 2
Refusal Form: Periodontal Treatment
Silver Diamine Fluoride – English, Spanish and Chinese
Treatment by Student
Treatment by Extern Dentist


Dental Practice Policies and Procedures

Dental Clinic Policies: Dental Radiology
Dental Clinic Policies: Emergencies
Dental Clinic Policies: Fire Safety
Dental Clinic Policies: General Information
Dental Clinic Policies: General Information 2
Dental Clinic Policies: Medical Emergencies
Dental Clinic Policies: Medical Referrals
Dental Clinic Policies: Payer Types
Dental Clinic Policies: Professional Nuggets
Dental Clinic Policies: Radiation Protection
Dental Clinic Policies: Record Management
Dental Clinic Policies: Referral Policy
Dental Clinic Policies: The Superbill
Dental Equipment Maintenance Log
Dental Sterilization Procedures
Denture Quote Sheet – Spanish
Encounter Form
Fee Estimate Form
Fee Estimate Form 2
Health History Form
Health/Medical History Form
Medical Consultation Request Form
Meeting Minutes Basic Format
Patient Policies: Broken Appointment Policy
Patient Policies: Patient Rights & Responsibilities
Pediatric: Parents in Treatment Rooms
Pediatric: Patient Management Techniques Information
Pediatric: Safety Steps Policy
Pediatric: Your Child’s Appointment
Record Retention Guide
Referral Form
Referral Follow Up Letter (English and Spanish)
Social Networking Policy


Guidelines and Instructions

Appointment Day Card – English and Spanish
Care after Extraction

Discharging a Patient
Dental On-Call Record
Fingernail Guidelines
Nitrous Oxide Day of Appointment Instructions – English and Spanish
Stainless Steel Crown Post Op
Wearing Your New Denture – English and Spanish


Human Resources Forms

Clinician Fitness Verification – Initial
Credential Committee Letter
Credentialing Checklist
Credentialing and Privileging Policy
Dental Assistant Competency Form
Dental Provider Privilege Request Form
Dental Provider Privilege Request Form 2
Front Desk Orientation Procedure
Incident Form
Job Description: Dental Director
Job Description: Dentist
Job Description: Dental Hygienist
Job Description: Dental Assistant
LIP Document Check
Performance Evaluation: Executive Director
Performance Evaluation: Executive Director 2
Performance Evaluation: Providers
Performance Evaluation: Providers 2
Roles and Responsibilities: Oral Health Manager
Sample Interview Questions: Dentist



Caries Risk Assessment Form
Clinic Audit Forms
Dental Navigation Sheet
Oral Health Self Management Goals
PDSA Dental Navigation
Peer Review Form
QA and QI Program Policy
Quality Assessment Plan

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