I. Consent Forms:

English: Authorization for Anesthesia; Dental Hygiene; Endodontic Treatment; Extraction of Teeth 1; Extraction of Teeth 2; 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

Spanish: Anestesia; Cirujia Oral; Endodoncia; Extraccion; Oxido Nitroso; Procedimientos Especiales; Tratamiento Dental

II. Refusal Forms: X-Ray Refusal

III. Excuse Letters: Excuse Letter

IV. Consultation Requests: Consultation Request; Medical Consultation Request

V. Policies & Procedures:

Financial:

English: 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; Patient Management Techniques; Patient Rights & Responsibilities; Policy; Professional Nuggets; ALARA Program

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

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

Spanish: Bebe Boca; Cancer de la Boca; Cuidar Dientes; Diabetes/Dental; Embarazo/Oral; Placa y el Sarro

For Providers:

Acetaminophen; Dental Access; Dental Issues; Dental Progs; Diabetes; Oral Health; Pediatric Dosing; Pregnant Patient

X. Miscellaneous:

Dental Equipment Maintenance Log; Levin Group Order Form; OSHA Material Safety Data Sheet; US Army Pregnancy and Postpartum Training

Twelve CHCs in Colorado operate 34 dental clinics in conjunction with their medical clinics. CHC dental clinics are located in the following counties: Adams, Alamosa, Boulder, Conejos, Costilla, Denver, El Paso, Larimer, Morgan, Otero, Prowers, Pueblo, Saguache, Washington, and Weld. CHCs provide high quality, cost-effective dental care, including emergency, preventive, restorative, and rehabilitative services, as well as oral health education and outreach services.

CCHN's Oral Health Project is staffed by Molly O'Fallon, Clinical Quality Division Director. Molly can be reached at mofallon@cchn.org or 303-861-5165 x224.

CCHN's Oral Health Project has received funding from the Bureau of Primary Health Care (BPHC) within the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services and from Rose Community Foundation.


Low-literacy Patient Education Materials:

Developed by the Colorado Oral Health Network

Dentures and Partials; Spanish; Russian; French
Diabetes and Your Teeth; Spanish; Russian; French
Oral Cancer; Spanish; Russian; French
Patient Etiquette; Spanish; Russian; French
Periodontal Disease; Spanish; Russian; French
Pregnancy and Oral Health; Spanish; Russian; French
Preterm LBW Babies; Spanish; Russian; French
Root Canal; Spanish; Russian; French
Tooth Removal/Dry Socket; Spanish; Russian; French
Your Baby's Teeth; Spanish; Russian; French

Other Online Resources Available

CCHN does not guarantee the accuracy or completeness of dental forms or links contained within this website and accepts no liability for the content of the forms 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 Health Center using these forms or links assumes all risk associated with their use.