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

 

Quality

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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