Forms & Guidance
Dental Patient Medical History
- IHS-42-1 Page 2 & 3 - Dental Patient Medical History [PDF - 219KB]
Oral Surgery
- IHS Form 964 & 965 - Consent for Oral Surgery, Anesthesia, and 'Time Out' Documentation [PDF - 70KB]
- Instructions on how to use the Oral Surgery Consent Form [PDF - 315KB]
Endodontics
- IHS Form 941 - Consent for Root Canal Treatment [PDF - 87KB]
- IHS Form 968 - Regenerative Root Canal Consent Form (11-2015) [PDF - 20KB]
Anesthesia/Nitrous Oxide
- IHS Form 967 Informed Consent Form for Nitrous Oxide [PDF - 43KB]
- GSA OF 522 - Request for Anesthesia and Operations [PDF - 574KB]
Pediatric
- IHS Form 966 Informed Consent for Use of Protective Stabilization [PDF - 22KB]
- IHS Form 974 - Informed Consent for Silver Ion Antimicrobials Treatment [PDF - 64KB]
Infection Control & Prevention
- IHS DOH (Dental Assistant) Infection Control Competency Assessment - General (2020) [DOC - 65KB]
- IHS DOH (Dental Assistant) Infection Control Competency Assessment - Transport and Sterilization (2020) [DOC - 56KB]
- IHS Dental Checklists for Ambulatory Setting [DOC - 74KB]
- IHS Dental Checklists for Hospital Setting [DOC - 72KB]
- IHS Ambulatory Setting Policy and Procedure #1 [DOC - 60KB]
- IHS Ambulatory Setting Policy and Procedure #2 [DOC - 41KB]
- IHS Dental Portal — Infection Control & Prevention [additional forms and guidance]
- CDC Guidelines for Infection Control in Dental Health-Care Settings — 2003 [PDF - 1.2MB]
- CDC Foundations: Building the Safest Dental Visit
School Sealant Program
- IHS Form 972 - School Screening, Fluoride, and Sealant Permission Form [PDF - 15KB]
- IHS Form 973 - IHS Report to Parent About School Dental Screening [PDF - 16KB]
Dental and Dental Hygiene Students
Photo/Video
- DHHS Appearance Release [PDF - 34KB]
- Photo Consent Release - Adult [PDF - 78KB]
- Photo Consent Release - Minor [PDF - 77KB]
Dental Pay
- HHS Form 691 - Title 38 [PDF - 1.1MB]
- Title 38 Instructions [PDF - 209KB]
- Justification for Title 38 [PDF - 56KB]
- Title 38 Narrative Example [Word - 38KB]
- Title 38 Pay Tables and Tiers [PDF - 387KB]
- 3-R Form [PDF - 384KB]
- 3-R Instructions [PDF - 207KB]
- 3-R Narrative Example [Word - 42KB]
- Case Checklist - Recruitment Incentive [PDF - 442KB]
- Case Checklist - Retention Incentive [PDF - 447KB]
- 3-R's HHS Policy [HHS Website]
- ADA - General Dentist Income Estimates from the Bureau of Labor Statistics (2021) [XLSX - 94KB]
- ADA - Income, Gross Billings, Expenses, Characteristics: Selected 2020 Results from the Survey of Dental Practice (Tables in Excel, Revised Dec. 2021) [XLSX - 754KB]
Old Forms
- IHS-42-1 Page 1 - Dental Examination Record [PDF - 12KB]
- IHS-42-2 - Dental Encounter Record [PDF - 34KB]
- IHS Form 514 - Periodontal Examination Record [PDF - 52KB]
If you have any difficulties with this website, contact DOH Portal Administrator.
