CLINIC FORMS

From the Clinic Manual

Contents 1 Comprehensive Care 2 Endodontics 3 Oral Diagnosis / Oral Pathology 4 Oral Surgery 5 Pediatric Dentistry 6 Periodontology 7 Miscellaneous Forms

Comprehensive Care

Patient Information Sheets

Indirect Fixed Restorations

Single Crowns and Fixed Partial Dentures Quality Assurance Form

Single Implant Treatment Approval Form

Crown and Bridge Start Card

Indirect Removable Restorations

Quality Assurance Control Form Removable Appliances

Implant Retained Overdenture Treatment Approval Form

Removable Prosthetics Start Card

Required Forms In All Dental Charts

HIPAA Notice of Privacy Practices

Radiographic Log

Optimal Treatment Plan Form

Alternate Treatment Plan Form

Medical-Dental History(Must be completely updated every two years)

History Update(For use between mandatory two year complete history updates)

Operative Chart

Periodontal Chart

Progress Notes

Patient Consent and Release Form

Other Comprehensive Care

At Risk Informed Consent Form

Lab Prescription Form

Case Risk Assessment Form

Patient Tracking Report Options Form(used during optional emergency clinics for students to receive credit for attending)

Patient Treatment Completion Exit Form With Instructions

Patient Transfer Evaluation Form(end of year)

PATIENT INFORMATION SHEETS

Treatment Staging Flow Sheet

Plaque Control Record

Check List for Treatment Planning

Diagnostic Impression Flow Sheet

Endodontics

Extracted Tooth Completion Form

Case Difficulty Asses Form

Endo Referral Form

Oral Diagnosis / Oral Pathology

Oral Pathology Requisition Form

Oral Surgery

Oral and Maxillofacial Case Sheet

Referral Form for Oral Surgery

Consent form for oral surgery and anesthesia

Post extraction instructions - For the patient

Pediatric Dentistry

Pediatric Dentistry Recall Form

Pediatric Dentistry Information Form

Patient Exam Form

Periodontology

Worksheet for Second Year Fall Periodontal Data Acquisition Competency Exam

Worksheet for Second Year Spring Periodontal Exam, Diagnosis, and Treatment Competency

Scaling and Root Planing CQE Criteria For Patient Selection

Periodontal Risk Assessment Form

Miscellaneous Forms

ExternshipRequestForm.

Theft in Clinics Report Form

Emergency Patient History/Evaluation

CASH SLIP

TREATMENT COMPLETE SATISFACTION SURVEY

Photo Release Form

Quality Assurance Challenge Form

Competency Driven Audit Form

Personal / Sick Day Out of Clinic Form

Change of Duty Form

Rev. 06/27/09