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Dental Forms in Word
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Informed Consent:
Discussion and Consent (generic form)
Informed Refusal:
Discussion and Refusal of Treatment
Discussion and
Consent for Crown Restorations
Discussion and
Consent for Extraction
Discussion and
Consent for Root Canal Treatment
Authorization
to Release Confidential Patient Information (Records Release)
Referral Letter
Patient Termination
Letter
Delta Dental Claim
Form (specify state)
DD Form 2813:
DEPARTMENT OF DEFENSE ACTIVE DUTY/RESERVE FORCES DENTAL EXAMINATION
$19.97
Fee Disclosure
Acknowledgement Form
Blue Cross/Blue
Shield Attending Dentist Statement (Dental Claim Form): $25
DD Form 2808 (3
pages) REPORT OF MEDICAL EXAMINATION:
DD 2871 (2 pages)
REQUEST TO RESTRICT MEDICAL OR DENTAL INFORMATION
DD 2870 (1 page)
AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
New Dental Patient
Information Form (3 pages) - see sample PDF here of our form.
New Dental Patient
Information Form (1 page)
HIPPA Policy and Notice of Privacy Practices for a private dental clinic - see sample PDF here of our form.
HIPPA Policy and notice of privacy practices for a university dental clinic
Dental Surgery Consent Form
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