In-Office Consent and Recommendation Form
Consent and Recommendation Form for In-Office Dental Screenings
This Consent and Recommendation form has been developed for use by dental professionals who provide dental screenings in private settings (large scale screening programs typically use a similar form). A dental screening is not a billable service. CDA encourages dentists to consider providing this basic service on an as needed basis, in private offices.
The form obtains consent from the parent for the screening, establishes the parameters of the service being provided, and informs the parent of the findings of the screening. CDA recommends the original copy of this form be given to the parent and a copy be kept on file for a period of one year.
Additionally, this form does not constitute and is not a substitute for legal or other professional advice. If legal advice or other expert assistance is required, the services of a professional should be sought.
Download Consent and Recommendation Form - English
Download Consent and Recommendation Form - Chinese
Download Consent and Recommendation Form - Hmong
Download Consent and Recommendation Form - Russian