Download AWESOME_LETTERBOOK

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It’s all in how
you say it!
Here’s how…..
©2009 Roz Fulmer, Making a Difference…Today!
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Table of Contents
Welcome New Patients .........................................................................................................4-12
Retiring, New Associate, New Location and/or Partnership ..................................................... 13-20
Unfinished Treatment, Treatment Proposed. Completed Treatment ............................................ 21-31
Missed Appointments, Dismissal from Practice....................................................................... 32-38
Past Due Accounts, Collections ............................................................................................. 39-42
Hygiene Recall, Recare, Patient Reactivation ......................................................................... 43-50
Release Forms: Photo & Model, Patient Records, Treatment Refusal .......................................... 51-61
Consent Forms ................................................................................................................... 62-75
Hiring and Firing Documents………………………………………………………………………76-98
©2009 Roz Fulmer, Making a Difference…Today!
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Here’s how…..
WELCOME
NEW PATIENT
©2009 Roz Fulmer, Making a Difference…Today!
3
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Your Letterhead
Here is a Potential New Patient Letter:
(Insert Today’s Date)
Potential Patient’s Name
Address
City, State, Zip
Dear (Potential Patient’s Name),
Welcome and we hope to see you at our practice!
Our entire team would like to invite you to our office to care for your dental needs.
The first impression that we are attracted to is people with wonderful smiles, wouldn’t you
agree? And nothing is more important to an attractive smile than healthy cared-for gums and
teeth. It is this kind of healthy attractive smile that we are committed to giving every one of my
patients. When you become a patient you will create a partnership, which will last through the
years. Our partnership is prevention oriented and dedicated to your health, we hope that is what
you are looking for, is it?
Our office hours are patient – oriented and we are available for emergency services as well
should you ever need them. Did you know that communication is important to us? We will
share with you, your treatment desires, needs and expenses in advance, as we believe in no
surprises. We will also assist with your insurance claim filing. We are here to serve you so
please do not hesitate to contact us regarding any matter as customer service is our number one
goal for our patients.
We welcome new patients and look forward to servicing you and your dental desires. Our
practice looks forward to a long and healthy partnership with you, your family and friends.
Yours in good oral health,
(Provider’s Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
4
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Your Letterhead
(Insert Today’s Date)
Here is a sample letter to send to a potential Patient met outside of the
practice either at a Social Function or just socially:
Dear (Potential Patient),
It was so nice meeting you at lunch today. We hope to see you at our practice!
Our entire team would like to invite you to our office to care for your dental needs.
The first impression that we are attracted to is people with wonderful smiles,
wouldn’t you agree? And nothing is more important to an attractive smile than
healthy cared-for gums and teeth. It is this kind of healthy attractive smile that we
are committed to giving every one of my patients. When you become a patient you
will created a partnership, which will last through the years. Our partnership is
prevention oriented and dedicated to your health, we hope that is what you are
looking for, is it?
Our office hours are patient – oriented and we are available for emergency
services as well should you ever need them. Did you know that
communication is important to us? We will share with you, your treatment
desires, needs and expenses in advance, as we believe in no surprises. We will
also assist with your insurance claim filing. We are here to serve you so please
do not hesitate to contact us regarding any matter as customer service is our
number one goal for our patients.
We welcome new patients and look forward to servicing you and your dental
desires. Our practice looks forward to a long and healthy partnership with you,
your family and friends.
Yours in good oral health,
Providers Name and his/hers Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
5
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Your Letterhead
Dear Neighbor,
As you can see, I’ve attached an Invitation to this letter. Why have I done this? Actually, there
are two reasons:
1) I have something very important to tell you, and I wanted to be sure this letter would
catch your attention.
2) And, since what I have to say concerns giving you a special invite to become our patient,
I thought using the invitation as an eye catcher was especially appropriate, would you
agree?
Here's why I'm writing:
My name is Dr. (Provider’s Name), and did you know that I am a dentist right here in your
neighborhood? Now wait, I know the first thing that comes to your mind in dentistry is “pain”,
am I right? Well, that couldn't be farther from the truth, at least so our patients tell us in our
office, it is “painless”.
Were you aware that dentistry has changed so much in the last few years? Sure, I still do all the
routine dental treatments such as fillings, cleanings, etc. and my goal is to prevent problems
before they ever occur. Would you believe that our patients thank us for helping them keep their
mouths so healthy?
When is the best time to see a dentist? Before you have a problem, wouldn’t you agree? That
way we can keep your mouth healthy and most likely prevent any problems! Are you a person
that would prevent a situation from happening or wait until a crisis happened?
Yes, modern dental care is exciting, comfortable and even fun! Cosmetic Dentistry is also
completed at our practice as well as your general needs.
Well, I would like to invite you to my office. I would be honored to have you as a patient here.
Besides the excellent care you will receive, here is what I'll promise you: My team and I will
make you feel at home. I will always give you an honest assessment of the condition of your
mouth? Did you know that at our office, our patients are in control of their treatment? They can
accept none, part or all of the treatment presented to them. Is that the kind of office you are
looking for when it comes to yours and your family needs?
If this sounds like the type of dental care you'd like to receive, why don't you call my
receptionist, Roz, right now at (insert phone number) to schedule an appointment. We are
conveniently located at 447 Tenth Street. in Merryville. I hope to hear from you soon. If you
have access to the World Wide Web, look us up at www.feelgoodsmiles.com where you can
learn more about our office, our team, and print our get acquainted forms.
Warm regards,
(Provider’s Name)
©2009 Roz Fulmer, Making a Difference…Today!
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Attachment to the Welcome to the Neighborhood Letters either as
an Invitation or Gift Coupon:
(Practice or Doctor’s Name) and Team
Request your help with the expansion of our practice
We cordially invite you, a family member or friend to become part of our Dental
Family.
You and they will receive a gift of $50.00 off a comprehensive examination
with the necessary x-rays needed.
Call Today to schedule your “Gifted” Appointment!
Our office hours are: Monday – Thursday 8:00 am to 5:00 pm
We are located at (Office address)
(Insert Phone number)
Name of New Patient: ___________________________________________
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
(Insert Today’s Date)
Dear New Homeowner,
Would you not agree that moving into a new area can be exciting and sometimes a bit
bewildering? My team and I would like to help make your search for a family dentist a little
easier.
We have a small, patient centered practice and have been in the Merryville area since 1990. Our
dental team prides itself on the time we spend with our patients, the quality of treatment and the
comprehensive educational approach to your dentistry. We schedule “on time” appointments
and take the time to get to know you and to fulfill your needs. Is that the kind of dental office
you are seeking?
To support you, our office files most insurance and offers other “Health Plan Options outside our
office. Our convenient business hours are as follows:
Mondays and Wednesdays
8:00 A.M. – 5:00 P.M.
Tuesdays and Thursdays
7:00 A.M. – 4:00 P.M.
Our Office Phone number is:
(insert your phone number)
Your comfort during every visit is one of our top priorities. We offer nitrous oxide (laughing
gas), stereo headphones (to block out sound), television glasses, topical anesthetic and more.
Our patients are amazed at how easy their dental care can be!
Your first visit includes a Dental Imaging and Records Exam that will allow you to see the
condition of your teeth, a full series of x-rays are necessary to completely diagnose your
condition, and a consultation with Dr. (Provider’s Name). You do want a complete record,
right?
In addition to being able to serve your family’s basic needs, such as cleanings and fillings, we
also have a reputation for excellent cosmetic dentistry. This type of treatment is selected by
those who want to improve the look of their smile through tooth whitening, correcting stains or
spaces between teeth, or replacing missing teeth. Have you ever experienced seeing what your
smile could be like with a computer imaging system? During your visit, please be sure to look
through our album of completed cases and our happy patient’s diary.
Finally, have your found inside this letter your Welcome to our Neighborhood Gift Coupon?
We look forward to meeting you when you come in to receive your free gifts from our office.
Sincerely,
(Provider’s Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Welcome New Patient Letter that will be coming in shortly for their initial appointment:
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Name of New Patient),
We are delighted to welcome you to our practice and are pleased that you have chosen us to be
your dental home. We are sincerely committed to serving you and providing superior dental care.
We are proud of our dedication to our patients. Our goal is to help you feel and look the very
best through excellent dental care. Is that what you want, also?
Your first appointment with us, scheduled for (appointment date) at (appointment time), will take
approximately one hour. Do you like to be seen on time? We will do our best to make that
happen by reserving time with the doctor for you alone! How does that sound? We also need
your help by completing the enclosed forms and faxing them to us, mailing them or bringing
them with you to the appointment. Which would be the easiest for you?
Do you need directions to our office? We are located at (insert your address and city).
Do you have current x-rays from your previous dentist? Would you please bring these with you
to your appointment? If you do not have any current x-rays we will be happy to take the
necessary x-rays during your visit with us. This will help the doctor collect all the important data
to properly diagnose your case. Does that sound reasonable to you?
Do you have dental benefits from your employer? We would be happy to research your benefits
for you prior to your appointment if you would like, would you? If you would kindly call our
office today with your dental carriers’ information, we can begin the research immediately for
you.
Would you like to know more about our office? We invite you to look at our website at
www.feelgoodsmiles.com. Our office phone number is (insert phone number) should you have
any questions or concerns prior to your upcoming appointment.
Thanks again for choosing our dental practice. We look forward to meeting you and serving your
dental needs.
Sincerely,
(Provider’s Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Welcome New Patient who has just completed their initial appointment:
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Insert Patient Name):
Our entire team would like to thank you for selecting our office to care for your dental needs.
We are committed to excellence and are well equipped to provide you with the finest dental care
available in a friendly and compassionate environment.
What are you seeking in regards to what your dental office should be offering you? This office
utilizes the latest in dental technology which includes the dental laser, dental imaging, and dental
education to make your visit to the dentist pleas-ant and informative.
Enclosed are your patient registration, dental & health history forms as well as our philosophy
for payment options. Please complete each of the forms and bring them on your first visit. We
ask for help from our patients when it comes to keeping their commitment with their scheduled
appointments. Will you help us by giving us at least a 36 hours advance notice should a
challenge arise with your scheduled appointment time?
If you have any questions, please do not hesitate to contact our office (insert phone number) at
your earliest convenience. We are looking forward to meeting you on:
______________________________________________ at _______________.
Sincerely,
(Provider’s Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Welcome New Patient Letter to Parents of a Child who has become a patient:
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Child’s Parents Name),
Thank you for selecting our office to care for your child’s dental needs. (Child’s name) was an
outstanding patient today and we were very proud of the care that she/he has received at home.
We need your help with keeping (child’s name) dental care as good today as it will be in the
future. We ask that you spend time daily with his/her physically helping to brush his/her teeth.
A child can do this most effectively when he/she has been shown how to, repetitively.
Development of good home care habits at an earl age will carry over for a lifetime of strong,
healthy teeth.
Remember, the only person who can accomplish this for your child is YOU!
Best in health to you and your family,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Welcome New Patient Letter to Parents of a Child who has become a patient:
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Child’s Parents Name)
Welcome to our practice! We are happy you selected us for your child's dental needs. Our intent
is simple---to give your child the best dental care available in a pleasurable environment. Our
goal is to help your child grow and develop into dental patients who will continue a life-long
practice of good dental care.
We appreciate the time you take to prepare your child for his/her visit to our office as your in-put
is most valuable. Explaining to your child in a positive manner that we will help them stay
healthy and to do this we will need to look in their mouth and examine their teeth and gums. A
cooperative and friendly relationship between the child and the dentist is so important. You're
the best person to judge how much and when to tell your child about the upcoming dental visit.
Some children will want to ask questions before the visit, while others may be best suited to
know the day of the appointment; this choice is up to you.
Upon your arrival, we will acquaint your child with our dental office and waiting room,
introduce ourselves and take your child's height and weight. Your child will then be invited into
the exam room where we will make your child feel comfortable and begin the examination,
which may include cavity-detecting x-rays. Every procedure will be explained and demonstrated
before beginning. In most cases, children are much more cooperative if parents are not present at
the time of examination and treatment. However we do understand that sometimes a child may
feel more comfortable with a parent present for their first visit. Thank you for your help and
cooperation.
Our guiding principal is "Children First" therefore following the best protocols as advocated by
the American Academy of Pediatric Dentistry. Our dental practice is committed to a policy of
prevention. We will respond to the patient's and their family's needs by being family-centered.
We share a common pledge---to do our best to help keep your child's teeth and mouth in good
health and to make your child's dental experience a pleasant and rewarding one.
Sincerely,
(Provider’s Name), D.D.S. and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
(Insert Today’s Date)
Here is an example of a “Congratulations to New Parents letter plus some valuable
information for them as new parents and babies first tooth.”
Patient’s Name
Address
City, State, Zip
Dear (Name of New Parents),
We are delighted for you and your family with your newest addition to your family, your
precious baby! What an exciting time for all of you. Did you know that new babies are
vulnerable little people and from the first day a new tooth erupts, new teeth are vulnerable, too?
As parents, there are ways you can protect your child from cavities and begin his/her dental
health on the right path.
Were you aware that your baby’s first visit to the dentist should be around the age of 12 months
or when the first teeth erupt? Prior to that first visit, below are a few reminders in keeping your
baby’s dental health HEALTHY:

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Rub with a washcloth or pad of gauze baby’s teeth and gums after each feeding or mealtime.
Baby’s diet is very important so avoid sugars in bottles when the baby sleeps.
Remember, fruit juices and milk, however healthy can cause early decay. It is
recommended that after 3 months, water at bedtime is best instead of milk.
Encourage your baby to use teething rings as chewing helps to break the gum tissue
faster, soothes the gums and erupts the teeth quicker for your baby.
Remember, your baby’s saliva works to cleanse their mouth and teeth during the day. As
your baby grows, spaces between teeth will begin to close, you will need to begin
flossing to protect the teeth and their fragile enamel.
We look forward to meeting this new addition to your family. Should you have any questions at
any time about your baby’s oral health, please feel free to call us at (insert phone number).
Sincerely,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Here’s how for…..
Retiring,
New Associate,
Partnership and/or
Location.
©2009 Roz Fulmer, Making a Difference…Today!
14
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Your Letterhead
(Insert Today’s Date)
Here is an example of “Announcing the Retirement from my Dental Practice”:
Patient’s Name
Address
City, State, Zip
Dear (Patient)
I would like to thank you for your trust and confidence in allowing me to serve as your dentist
through the years. It is with mixed emotions that I am announcing my decision to retire from
dentistry and to have another dentist acquire my practice.
Because I want to be certain that my patients continue to receive the best possible care, I have
selected Dr. (name) to carry on my practice. I believe that (he/she) is a competent and caring
person who has the qualifications and desire to continue the practice in a highly professional
manner that you were accustomed to during my years as your dentist.
Dr. (name) is from (City, State). He/She is a (year) graduate of (dental school) and presently
practices dentistry in (City, State). Dr. (name) is a member of the (State) Dental Society, (City)
District Dental Society and the American Dental Association.
I will give Dr. (Name) your records, unless you advise us to do otherwise. I feel confident that
Dr. (Name) will continue to provide you and your family with the best possible dental care. If
you would like your records transferred elsewhere, please let us know within the next 30 days.
Dr. (Name) and your dental team will be contacting you for your next regularly scheduled visit if
you are not already scheduled. If you need any emergency care prior to your regular scheduled
appointment, please feel free to contact Dr. (Name) at the same number, which is (insert phone
number) and the office hours are remaining the same as well which are: Monday – Thursday
8:00 am – 5:00 pm. The after hours emergency number as of (date) will be (insert phone
number).
Thank you again for your past years of loyalty, friendship and confidence to me.
Sincerely yours,
(Provider’s Name), DDS
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is an example letter of “Announcing a new Associate or Partner” to the Practice
Dear Patients,
We are pleased to announce that our dental team has a new member; Dr. (name). Dr. (name)
graduated from (school) in (year) and has been practicing in (location) for (number) years.
She/He is an active member of the American Dental Association, Illinois Dental Association and
our local Illinois Valley Dental Society chapter and is a member of the Crown Council, alumni
with DOCS- Dental Organization for Conscious Sedation.
Dr. (name) has a caring patient manner; patient satisfaction first and foremost is her/his mission
statement. She/He has a special interest in (specialty area). Dr (Provider’s Name) and his team
have every confidence that Dr. (name) will be a strong asset to their dental team as well as bring
sedation dentistry to this practice.
We encourage you to come and meet Dr. (name) at a reception that our office will be holding in
her/his honor on (give date & time). We want you to experience and appreciate her/his skill as
an excellent dentist.
Dr. (name) shares in our practice philosophy of providing you with the highest quality of dental
care to you and your family today, as you have come to expect from our practice in the past.
Should you be in need of an appointment, please give us a call today to schedule an appointment.
Sincerely,
(Provider’s Name) DDS and Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Patients Name),
As you well know, Dr. (Provider’s Name) is retiring and wanted to leave his patients in excellent
care like they have received from him. His search is over and let us introduce to you, his
successor. Dr. (name) has been practicing dentistry in (location) for (number) of years since
his/her graduation from (school). Dr. (name) is an active member of the American Dental
Association, (State) Dental Association and our local Dental Society chapter
Dr. (name) has a caring patient manner; patient satisfaction first and foremost is his/her mission
statement. He/She has a special interest in (specialty area). Dr (Provider’s Name) and his team
have every confidence that Dr. (name) will be a strong asset to their dental team. We encourage
you to come and meet Dr. (name) at a reception that our office will be holding in his/her honor
on (give date & time). We want you to experience and appreciate his/her skills as an excellent
dentist.
Dr. (name) and our entire office are committed to providing the same highest quality of dental
care to you and your family today and the future, as you have come to expect from our practice
in the past.
See you at the reception,
(Provider’s Name), Dr. (new owners name) and Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Here is an example of Dentist relocating from the area, former dentist sending to patients a
referring office for their care:
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear Patients,
You recently received a letter from Dr. (Provider’s Name), stating that, regrettably, he will be
moving from our area. He mentioned that your records are now with our office, Dr. Merryville
and Dr. Jones. We appreciate the confidence that Dr. (Provider’s Name) has placed in us for your
dental care. Our office’s philosophy is to make this transition a smooth one for all of Dr.
(Provider’s Name)’s former patients as we realize that change is not always easy for many.
Dr. Merryville and Dr. Jones as well as our team, are honored to welcome you as new members
of our dental family. We know you will find us warm, caring and committed to the best for your
dental health. We want to be a part of your personal health and wellness team.
Did you know that Sue and Sara, Dr. (Provider’s Name) hygienists are now part of Dr.
Merryville and Dr. Jones’s team as well as LaVonne and Kathy, your former assistants? They are
a part of our dental family to assure you to feel at home in our practice too.
Many of you have questions about our office. Some of them might be:
1. What about my insurance and what financial arrangements do they offer?
2. Will the appointments work with my schedule?
3. Are they pain-free dentists?
4. What about the treatment I need now?
5. What about the quality of their work?
We want to make this transition as comfortable for you as possible so we have arranged for you
to have a personal concierge, Roz, to aid you in the process. We have a special phone line set up
for you to call and speak with Roz as she is here daily from 8:00 am to 5:00 pm. Please call her
today at (insert phone number) and she will help you become acquainted with our office.
Once again, we are honored to welcome you to the family! We look forward to serving you in
the near future.
Sincerely,
Drs. Merryville and Jones, DDS & Team
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Here is a sample of Practice Relocating to New Location:
Drs. I. Feelgood and T. Merryville D.D.S.
Clause Blvd Suite 100
Merry City, IL 66666
Phone: (insert phone number)
Fax #: (insert fax number)
We are pleased to announce the dental practice of Drs. Feelgood and Merryville will be
relocating to a new location, Clause Blvd., Suite 100. Phone number will remain the same
(insert phone number).
Our new office is designed to offer a more comfortable convenient (main floor) facility for you
and your family. It features an attractive reception area, spacious treatment rooms and the latest
in dental equipment and technology. Drs. Feelgood and Merryville have always strived to
practice state -of-the-art dentistry, keeping the practice on the cutting edge of the dental
technology.
Although we’ll be in a new location, we will not be changing our office hours (state hours), or
our outstanding dental team, who are there to give you the exceptional care that you have been
given in the past.
Our last day in our present location is set tentatively for (State your last day of operation). The
new office will be open on (State opening day and time). Arrangements are already made to
provide emergency coverage during this transition period, please call our regular number (insert
phone number) should you be in need of emergency care.
We are looking forward to seeing and serving you at our new office. Please come by and check
it out! Again, the new location is: Clause Blvd Suite 100
Merry City, IL 66666
Phone: (insert phone number)
Fax #: (insert fax number)
Looking forward to seeing you soon at our new location,
Drs. I. Feelgood and T. Merryville D.D.S. and Team
©2009 Roz Fulmer, Making a Difference…Today!
19
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Your Letterhead
Here is a sample of Practice Relocating to New Location:
(Insert Today’s Date)
Wow!
Was that you first reaction when you first heard that we were relocating to a new address? Some
of you might have wondered, Why is he/she moving? Our cute reply is that it is a mid-life crisis
but it really isn’t that. It is for you!
Dentistry is changing all the time and for the better each and everyday. Our former location was
too small for the newest equipment that we need to take better care of you. This is what you
deserve and we want to give it to you, we want to reflect our esteem for you.
Our reason for the move also goes far deeper for us. This new office converges our mission
(dentistry), our vision (an ethical society), and our passion (our patients). How many of us will
have such an incredible opportunity in our lifetimes? This is not just where we are privileged to
work, but where we are more privileged to meet new friends as our patients are our friends and
where we share laughter, joy, sorrow and fun. Yes we do have fun in the dental office!
We have had a wonderful relationship over the years and we hope to continue that as well at the
new location and to take it even to a higher level. We want you to be proud of your dental home,
a place to refer your family and friends, proud of our values, for what we stand for, something
truly significant.
Please feel free to share this letter with anyone that may be in need of our services. Any friend
of yours will be a friend to us as well.
One day, we will look back at all of this and really say,
Wow!
We are looking forward to seeing and serving you at our new office. Please come by and check
it out! The new location is: Clause Blvd Suite 100 Merry City, Phone: (insert phone number)
Looking forward to seeing you soon at our new location,
Drs I Feelgood and T Merryville D.D.S. and Team
©2009 Roz Fulmer, Making a Difference…Today!
20
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Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample for “Announcing the Additional Office Location”:
Dear (Patient),
We are so pleased to announce the opening of a new dental office location for your convenience,
located at (New Location Address, City). According to our patient survey that you helped with,
an additional office location in (new location) will make services more convenient to a number
of our patients in that area.
If our new office location is most convenient for you, we stand ready to meet your dental needs
at this location serving you the same times that you were used to, which are 7:00 am – 6:00 pm
daily, Monday thru Thursday.
The new (Name of Location) facility is bright, spacious and comfortable. It features the latest in
dental equipment and although it is a new location, you will still receive the same caring, quality
dentistry from our professional dental team. Patient satisfaction is still our number one priority,
no matter where we are located.
Please feel free to stop by for a tour or call us at our new location to schedule an appointment or
to transfer you already schedule appointment at the new location. The new phone number for
this location is (insert phone number). Enclosed please find new business cards magnets with the
new location’s address and phone numbers.
Sincerely yours,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
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Here’s how for…..
Unfinished Treatment,
Treatment Proposed
Completed Treatment
©2009 Roz Fulmer, Making a Difference…Today!
22
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Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Uncompleted Perio Treatment:
Dear (Patient’s Name):
Would you please accept this letter as a reminder that on (Date of their initial visit), we
performed a preliminary treatment, which removed most of the heavy tartar build up on your
teeth? Were you aware that this treatment was only the initial step in the process of restoring
you to total oral health?
1. Do you recall, due to the amount of tartar on your teeth, we were not able to determine
the amount of gum disease or infection present in your mouth?
2. Are your gums still bleeding like they did when we saw you last December?
3. Do you believe that bleeding gums are a sign of not being healthy?
4. Wouldn’t you agree that it is necessary that we re-evaluate your condition and complete
any necessary treatment needed to clear up your infection?
It is our goal is to be your partner in optimal oral health. Do you see any reason why we couldn’t
schedule you to complete your treatment? If we do not hear from you by the end of the week,
please expect a call from our office to schedule your appointment. We are very concern for you
and overall health. Our office number is (insert phone number) and our office hours are
Monday – Thursday 7:00 am – 4:00 pm.
Yours truly in Good Oral Health,
Providers Name and Hygienist Name
©2009 Roz Fulmer, Making a Difference…Today!
23
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Uncompleted Perio Treatment:
Dear (Patient Name):
Do you recall that when you were last here for your dental visit, we measured the “pockets”
around your infected teeth? This was done with a ruler to determine how far along your bacteria
infection had progressed, remember? Did you know that this infection can be stabilized with
consistent treatment by your hygienist and your home care?
The treatment to be completed by your hygienist will consists of a more deter-mined “tooth”
cleaning, which will include beneath your gum line to clear away the bacteria, toxins that are
causing this infection. You will receive anesthetic throughout your treatment to keep you “painfree”. Your comfort throughout the procedure is our number priority, is that you are wanting as
well?
Once we have completed these visits, we will need your help in maintaining and keeping this
infection in remission, will you be our partner in keeping you healthy with your oral health?
Routine visits of every 3 – 4 months with our hygienist will be the key to successfully keeping
this infection in remission.
Please call our office today at 555-222-4444 to schedule your appointment. We look forward to
your call and to getting you “infection” free!
Your oral health care partners,
Providers Name and Hygienist Name
©2009 Roz Fulmer, Making a Difference…Today!
24
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Overdue Perio Maintenance:
Dear (Patient Name):
Upon updating our files we have found that your periodontal maintenance appointment is past
due, can you believe it? You were last treated in our office with a non-surgical gum tissue
treatment on (last date). The success of this treatment directly depends on your diligent home
care and routine maintenance visits. How is it going for you?
Did you know that gum disease is similar to diabetes in the fact that it cannot be cured, but can
easily be controlled with gum treatment and ongoing care? This means that in the absence of
regular maintenance visits the chances of you having your periodontal disease quickly resurface
and cause debilitating effects to your teeth, bone and gum tissues are very high, were you aware
of that? As you may recall, untreated gum disease can result in tooth loss and especially bone
loss.
We want to ensure that your “gum infection” remains in remission and that your gum treatment
continues to be a successful part of your oral health, do you want this as well? We would like to
regularly monitor your gum and bone tissues every 3 months, will you allow us to do this for
you? These maintenance visits can inevitably save you future discomfort, extensive and
expensive dental treatment and help preserve your natural teeth for a lifetime. We hope this
information enables you to make a well informed choice about your oral health. Therefore, we
are requesting that you call us at your earliest convenience to schedule your necessary
periodontal (bone and gum tissue) maintenance visit. Remember, our office number is (insert
phone number) and our office hours are (state your hours here). Looking forward to your call.
In the Interest of Better Health,
Provider and Hygienist name
P.S.
Please read the enclosed new findings on the relationship of Periodontal disease and heart
attacks.
©2009 Roz Fulmer, Making a Difference…Today!
25
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is an example of a “Proposed Treatment not Accepted letter”.
Patient’s Name
Address
City, State, Zip
Dear (Patient Name),
Have you received our phone messages? We are really concerned about your oral health
condition. Dr. (Provider’s Name) asked that I write you a note about your proposed dental
treatment plan. Do you remember at your last visit, you & Dr. (Provider’s Name) discussed
what was needed for you to obtain good overall dental health?
Dr. (Provider’s Name) is worried for you concerning several areas of decay that he felt should be
Addressed right away. They have not started to hurt you yet, have they?



Did you know it has been proven that the best way to control dental diseases is through
diligent and consistent removal of plaque?
Are you aware that some dental conditions are painless, by the time you have
experienced discomfort, significant damage may have already occurred?
Did you know that Oral cancer is on the rise and of all the major cancers; it has the worst
5-year survival rate? The earlier it’s detected the better.
We are very concerned for you and your overall health. Our office number is (insert phone
number) and our office hours are Monday – Thursday 7:00 am – 4:00 pm. If you have chosen to
continue your dental care elsewhere, please call our office so that we may update your record to
inactive. Remember, you are always welcome to our practice if you should choose to return.
Yours truly in Good Oral Health,
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
26
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Treatment Pending:
Dear (Patient name),
Dr. (Provider’s Name) asked that I write you a note about your proposed dental treatment plan.
Do you remember at your last visit, you & Dr. (Provider’s Name) discussed what was needed for
you to obtain good overall dental health? . Dr. (Provider’s Name) is worried for you concerning
several areas of decay that he felt should be addressed right away. They have not started to hurt
you yet, have they?
Did you know that I had tried several times to reach you? I wanted to see if you had any
questions regarding the discussed treatment plan that you and Dr. (Provider’s Name) had spoken
about, do you? We want to let you know that you are welcomed to call our office any time with
any questions or concerns that you may have, our number is (insert phone number). Our office
hours are Monday – Thursday 8:00 am to 5:00 pm, we are looking forward to hearing from you
to be-gin your treatment.
We hope that you will take a few moments out of your busy schedule and give us a call, will
you?
Yours Truly for Good Oral Health,
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
27
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is an example for an unfinished Crown:
Patient’s Name
Address
City, State, Zip
Dear (Patients Name),
Do you remember we treatment planned that a crown would be needed for tooth # , in the
upper/lower area of your mouth? We shared with you at that time, it would take two (2)
appointments, one for the prep and the second for the cementing of the crown. We completed
the first appointment on (date) to prepare it for the lab to make the permanent crown. Now it’s
time to complete your treatment! Did you know that if the permanent crown is not seated within
a short time period, complications might occur? We want to avoid that for you. Would you
please find an hour of your time within the next two weeks for an appointment at our office?
Please call TODAY to get that scheduled in a time that will work best for you. Our office hours
are (state hours) and our phone number is (give phone number).
We look forward to your call
Sincerely yours,
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
28
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Treatment Pending:
Dear (Patient’s Name),
Were you aware that you have treatment pending from your last visit to our office? While we
respect your right to proceed with treatment at your own pace, we also feel the need to make you
aware that areas of decay or localized gum disease can progress rapidly if left untreated for even
a few months, did you know this?
Our goal at Feelgood Dental Care is to make it affordable for you to have both the treatment you
need, and want. Did you that we recently adopted a new financial policy that will allow you to
save from 3-15 % off your treatment plan, depending on the payment option you chose?
In addition, we now have a relationship with Dental Fee Plan and Care Credit, our Health Plan
Options which are interest free thanks to Dr. (Provider’s Name) as he is paying all interest for the
first 12—18 months, isn’t that great? In other words, having the incredible smile and optimal
dental health you desire can be affordable with low, manageable monthly payments. Dr.
(Provider’s Name) believes that no dental problem should become a financial burden for
his patients.
To give you an idea of the significant savings available, we have enclosed a copy of your most
recent treatment plan and an explanation of the savings we can now offer you. Should you
decide the Interest Free Health Plan Option is more manageable for your budget, you may call
Roz, our financial coordinator at (insert phone number) and she will be happy to assist you with
the application process. It only takes a minute of your time.
We hope to hear from you soon, as it is our utmost desire to keep you healthy while minimizing
your investment in your dental health.
Sincerely,
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
29
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Treatment Completed:
Dear Patient;
I and my team would like to thank you for your time and cooperation in the completion of your
recent dental treatment at our office. It is a great pleasure to serve patients like yourself and
greater satisfaction that you had placed your confidence in us and appreciated our work. We are
sure you will enjoy the results of both our efforts.
Time is precious for most people, and I know that the time you invested with us will prove well
spent. It is important to ensure that both your time and financial investment is well protected.
We will help you do so by scheduling you periodically for the preventive checkups and cleanings
necessary to maintain your dental work and keep future treatment to a minimum.
As always, if you have any questions or need any assistance, please don’t hesitate to call (team
member’s names), or myself.
Sincerely,
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
30
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for Treatment Completed:
Dear (Patient Name),
Congratulations on completing your dental treatment. My team and I have enjoyed working with
you. Would you mind if we make some suggestions for maintaining your healthy mouth and an
attractive smile in the future?
1. We'd like to continue the great partnership we have begun. Would you agree that our job
is to give our patients top-quality care with their treatment? Your job is to properly
maintain your treatment by brushing, flossing passionately and by keeping your
commitment to your recare visits. Did you know that many people like to schedule their
recare appointments months in advance to get the time and day that works best for their
busy schedules? If we haven't gotten you scheduled yet, ask us to make these
appointments for you now.
2. If you notice any changes in your mouth between checkups, or if anything in your mouth
becomes uncomfortable or painful or something just doesn’t feel right, please call us
immediately. Don't let it wait - the earlier corrective treatment occurs, the easier it tends
to be for our patients.
3. Isn’t it wonderful that the world of dentistry is constantly changing for the better? If you
don’t mind, we'll be sending you a newsletter filled with information to keep you
informed about the awesome changes happening for our patients at our practice.
We'd like to take this opportunity to thank you once again for choosing our office. We look
forward to your future visits. Will you help us expand our practice? The highest thanks we
receive from our patients are when they refer their friends, family, and co-workers to our office.
We hope your experience here has been positive enough that you consider this. We want to
expand our practice with patients who are just like you, WONDERFUL!
Best wishes from all of us for continued dental health.
Providers Name and Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
31
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Congratulations!
(Patient’s Name)
We’ve come a long way! Doesn’t it feel good to have achieved renewed oral health these past
few weeks and months, not to mention the wonderful benefits for you? Your gums and teeth
look over-all healthy, do you feel the same way?
Do you know the “Rules of the road”: the importance of keeping your regular Recare
appointments every 3 months? We need to monitor your ongoing periodontal health plus your
overall oral health, especially your implants at those appointments. You may experience
occasional flair-ups, don’t worry. Please call us if any-thing seems suspicious.
Remember, you have been given the tools of the Rotadent toothbrush, the Water-Pik, floss and
toothpicks plus your determination to stay healthy. We are so proud of you and the investment
you have made for your over-all oral health.
We thank you for being an excellent patient. Were you aware that we would like more great
patients like you in our practice? Should you have any friends or family members who could
benefit from the quality care we provide, please give them our name and phone number. We are
enclosing some of our business cards for you.
Yours truly in Dental Health,
(Provider’s Name)
©2009 Roz Fulmer, Making a Difference…Today!
32
_____________________________________________________________________________
Here’s how for…..
Missed
Appointments
&
Dismissal from the
Practice
©2009 Roz Fulmer, Making a Difference…Today!
33
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a “NO SHOW Letter to Patient” regarding a missed appointment:
Dear (Patient’s Name):
We are sorry that you failed to keep your dental appointment on ___________________.
Our office was very concerned that something happened to you on your way to your
appointment, did it? When we did not hear from you we became quite concern for you. Were
you aware that your appointment was a reservation for a seat in a dental chair, for treatment by
the doctor or hygienist? You and only you were going to be seen at that specific time of day.
We try to respect your valuable time by seating you promptly, unless we have been delayed by
attending an emergency patient. Have we failed you in this manner?
Did you know that when you do not show up for your scheduled appointment, we all lose the
following?
A. You, the patient, do not receive the treatment you needed or wanted.
B. A patient, who needs treatment immediately and cannot be seen do to a full schedule,
loses because we are booked with your appointment.
C. Everybody loses due to the fact that the time is lost time as we still believe that you may
show up for your appointment and could not refill it.
We schedule your time with us just for YOU. We did confirm your appointment time with you,
didn’t we? If we failed to give you a courtesy call, we apologize. We need your help, in the
future; would you please give our office 48 hours notice for any appointment you are un-able to
keep? We are committed to being here for you and we ask for your commitment as well. Will
you be here the next time?
Sincerely yours,
Providers Name
©2009 Roz Fulmer, Making a Difference…Today!
34
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample letter for a Missed appointment:
Dear (Patients Name),
We’re sorry you were not able to keep your scheduled appointment with us today. We hope there
is nothing seriously wrong, is there?
Do you remember that we spoke to you about giving us at least a week notice should you have to
change your appointment? Your case was special because you were going to be our “only”
patient at that time for the day so that you would have had our undivided attention throughout
your treatment.
If you could have notified us, the time in the schedule could have been given to another
individual, were you aware of that? This would have given us the chance to provide care to
another patient who may be waiting for an earlier appointment. I’m sure you understand our
desire to provide care promptly to our patients, like we may have done for you in the past.
Were you aware that when a patient breaks an appointment it is customary for a charge to be
applied? Your credit card will be charged $___________ for the broken appointment. Should
you reschedule your appointment within the next 3 months, the entire fee will be credited
towards that total cost of your treatment.
Please call our office as soon as possible to schedule another appointment. Your continue care is
very important to us and we hope it is to you as well.
Sincerely,
Providers Name
©2009 Roz Fulmer, Making a Difference…Today!
35
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is an example of a Patient Dismissal letter:
Dear (Patient’s Name),
You probably wouldn’t agree would you that Dentistry is an exciting profession? Would you
agree that as in all professions, a dentist is able to approach perfection for all his patients, when
he is working in an atmosphere of complete confidence and trust with his patients? As a patient,
would you not want a great rapport with your dentist at all times?
Unfortunately, we have not been able to reach that rapport with you. Would you mind telling us
why we have not been able to help you see the value of our services for you or the importance of
your dental care needs?
We feel that we have lost your trust and confidence so we believe that it would be better for you
to seek another dentist for your needed treatment since we do not seem to be the office for you.
Please understand that we have no ill feelings, absolutely none! We have your best interest at
heart and want you to be happy and most importantly, satisfied with your dentistry and your
relationship with your dental office. For some unknown reason, we can’t seem to fulfill your
satisfaction with our office.
For the next 30 days, while you are locating your new dental office, we will be your emergency
care office should you need treatment. Enclosed is a record release form that you may sign and
either mail or fax back to us so we may forward your dental records onto your new provider, as
without this release we cannot release your records according to the HIPAA laws.
Sincerely yours,
Providers Name
©2009 Roz Fulmer, Making a Difference…Today!
36
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample for Patient Dismissal from Practice:
Dear (Patients Name):
Did you know that we were really surprised that you failed to come in for your appointment on
___________? Were you aware that this is not the first time you have either cancelled, missed
without much notice to our office? Have we done something to cause you to not value our time
or services that we give to you and all our patients? Here is a list of appointment dates and the
hours that you did not keep:
Do you know what we must do now in regards to you and your dental care? We will be your
emergency dental care provider for the next 30 days, ending _______________, after which your
records will be forwarded to whomever you ask us to send them to for your continued dental
care.
Finally and most importantly to you, did you know that you still have needed treatment that
needs Addressing before you incur a problem? We do hope that your new dental office will be
better able to convey to you the importance of your dental treatment than we were.
Sincerely yours,
Providers Name
©2009 Roz Fulmer, Making a Difference…Today!
37
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample for Patient Dismissal from Practice:
Dear (Patients Name):
I’m writing to recommend that you secure the services of another dentist. I want you to be as
happy and satisfied as possible in your dental treatment and feel this change will ensure that
satisfaction, as we do not seem to be giving you what you want here at this time.
I have reviewed your clinical circumstances and determined that your dental health will not be
jeopardized by such a change. I urge you to place yourself under another dentist’s care without
delay so that you can continue a sound program of dental care. I will be available to attend to
your emergency dental needs for the next thirty days. This should give you ample opportunity to
select another dentist.
You may wish to contact the local dental society at (insert phone number) for a referral to
another American Dental Association member dentist. Please contact me if you would like me
to recommend another dentist.
Upon your written authorization, I will gladly forward your treatment records and other pertinent
information to your new dentist, if you so desire. Please contact my office for a release
authorization form. Again, I am sorry that we were not the dental home that you desired.
Sincerely,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
38
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample of Patient Dismissal from Practice:
Dear (Patients Name):
Patient’s total dental health care is our NUMBER ONE GOAL! We believe YOU do not feel
the same way, are we right? Several months ago when you were in our office, you were
presented with a complete treatment plan as to where your future lay with your oral health; do
you remember us talking about this?
Unfortunately, you have never called our office to set up any other appointments to complete
your treatment. Is there any special reason as to why you have postponed calling? We apologize
to you for any miscommunication or lack of trust we must be having with you in regards to your
dental health.
YOUR cooperation is necessary for our office to give you proper dental care and treatment. It is
with great regret that we do not have your trust and cooperation in this matter. We feel that we
are probably not your dental care provider in any other position except when you see the need,
usually in an emergency basis only, is it not?
Therefore, after 30 days from this date, we will forward your records onto whomever you choose
to complete your dental care. Again, we regret sending you this notice but you have left us no
other choice as we only want what is best for you, good oral health.
Sincerely,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
39
_____________________________________________________________________________
Here’s how for…..
Passed Due Accounts
&
Collections
©2009 Roz Fulmer, Making a Difference…Today!
40
_____________________________________________________________________________
Your Letterhead
One to two phone calls, and no more than two letters should be sent out within a 45 day
period to collect overdue balances and done with a “Smile” on our faces. Here are 3 letter
being presented, in the order that they should be sent. The final two send certified and
registered in a colored envelope so that a receipt is sent back to you for your records.
Here is an example of the first collection letter:
Past Due Balance
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Dear (Name of Patient):
Did you know, it has been several months since you have paid on your account? We are at a loss
and surprised as to why you have not responded to our statements and phone calls. You did get
our messages and statements, didn’t you? We have your current Address as
___________________________________________________, is this still correct?
Your current balance is $_____________.
At this time, our accountant is asking that you pay the entire amount of ____________ by
________________ or he will be forced to refer your account to our collection attorney. As a
valued patient we are sure that you would not want this collection action to take place, would
you? Please call our office immediately to speak with our administrative team to correct your
past due account with us? If there is a financial burden at this time, please call us and let us help
you with this balanced due, will you?
We accept payment in the form of cash, check or credit card.
Thank you for your help in this matter.
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
41
_____________________________________________________________________________
Your Letterhead
First and maybe even two phone calls have been made, first letter was sent 10 days ago and
still no response, NOW WE NEED THE BIG GUNS to help us collect.
Here is an example of the Letter #2, Credit Bureau Letter:
Patient’s Name
Address
City, State, Zip
Dear (Patients Name):
Since you have not replied to our previous correspondence, you leave us no choice but to re-port
this account to the Credit Bureau in your area. However, we would prefer to have you resolve
this matter, wouldn’t you? Please indicate your preference below:
1. I would prefer to settle this account. Please find my payment in full enclosed.
2. I would prefer to have you charge my Visa or MasterCard account; my
Credit Card Number is __________________________________________
Expiration Date _________________ Security Number (3 digits) ________
Signature: _____________________________________ Date: _________
If payment in full is not received within 10 days, our office will report this bad debt to your
Credit Bureau. Did you know that reporting your bad credit with our office will remain on your
credit report for a minimum of SEVEN years? We hope that you will take this FINAL
opportunity to avoid damage to your credit rating as this is not something that we wish to do,
were you aware that you are forcing us to do it? Please respond to this request to resolve this
matter before we are forced to take further action. Our attorney has requested that we do what
ever is necessary to be paid for our services rendered to you in good faith. Please contact us if
there are any problems or circumstance that we should know about as we want to work with you,
do you want to work with us, is the final question, do you?
Sincerely,
(Providers Name)
©2009 Roz Fulmer, Making a Difference…Today!
42
_____________________________________________________________________________
Your Letterhead
Now, thirty days have gone by and we still do not have any response from our patient, this
final letter is sent and once again as with the last letter, it is sent in a colored envelope with
no return address, only on the registered and certified United States Postal card for their
signature of receipt for this letter.
Here is an example of the Collection FINAL NOTICE Letter to attorney:
Statement of Delinquency
(Insert Today’s Date)
Name of Guarantor for the Account
Address of Guarantor
Dear
The above named responsible person(s) is delinquent in payment for services rendered to either
you or a family member for which you are the responsible party. Per our signed agreement of
said(state payment arrangements) payments were to be made, unfortunately your account has
become quite delinquent with no (state number of payments made if any) payments. Your
remaining balance owed is $__________.
We have always provided our patients with the finest treatment that modern dentistry has
to offer. Therefore, as a courtesy, we had extended credit to you and filed your insurance.
For this we expected payment in a reasonable and timely manner, no more than 60 days
after treatment was rendered, do you not remember our signed agreement?
FULL PAYMENT OF $____________ is due within the next 5 days of certified receipt of
this letter. Further action will be taken should non-payment be rendered after the final
due date has expired (type in due date). Unfortunately for you, the action that will be
forthcoming will be with our COLLECTION ATTORNEY. All court and attorney fees
will be the sole responsibility of you, the owner of this outstanding debt owed.
THIS IS FINAL NOTICE FOR THE ABOVE RESPONSIBLE PARTY NAMED
Thank you!
(Provider’s Name) and Name of Financial Coordinator
©2009 Roz Fulmer, Making a Difference…Today!
43
_____________________________________________________________________________
Here’s how for…..
Hygiene Recare
&
Patient Reactivation
©2009 Roz Fulmer, Making a Difference…Today!
44
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is an example of finding out if the patient still wants to be considered “active” in your
practice.
Dear (Patients Name),
Did you know that we have made several attempts to reach you in order to schedule your next
dental visit? Did you get our messages and/or letters, postcards, e-mails about your overdue
status for your dental care visits? We don’t want to continue bothering you, but want you to
know how important you are to us as well as your overall oral health condition is to us.
Were you aware that regular professional cleanings not only help protect the investment you
have made in your smile, plus it also help us to monitor the health of your teeth and gums? Did
you know that bacteria in the mouth could spread rapidly possibly destroying healthy bone? The
good news is that at your regular recare visits this gum disease can often be avoided or at least be
kept under control.
Remember, we are your partners in your dental care, right? Should we continue to keep your
record “active, current, a patient of record”? Would you be so kind to at least call our office at
(insert phone number) with you decision to schedule or to make your record “inactive”? Thank
you in advance for calling us with your decision.
We look forward to hearing from you as we have missed you.
Our office hours:
Monday - Thursday---700 am to 400 pm
Office number is: (insert phone number)
Sincerely,
(Provider’s Name) and Name of Hygienist
©2009 Roz Fulmer, Making a Difference…Today!
45
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is an example letter of “D4910 Perio Maintenance Recall Letter”
Dear (Patients Name),
Upon updating our files we have found that your periodontal maintenance appointment is past
due, can you believe it? You were last treated in our office with a non-surgical gum tissue
treatment on (last date). The success of this treatment directly depends on your diligent home
care and routine maintenance visits. How is it going for you?
Did you know that gum disease is similar to diabetes in the fact that it cannot be cured, but can
easily be controlled with gum treatment and ongoing care? This means that in the absence of
regular maintenance visits the chances of you having your gum infection quickly resurface and
cause debilitating effects to your teeth, bone and gum tissues are very high, were you aware of
that? As you may recall, untreated gum disease can result in tooth loss and especially bone loss.
We want to ensure that your gum infection remains in remission and that your gum treatment
continues to be a successful part of your oral health, do you want this as well? We would like to
regularly monitor your gum and bone tissues every 3 month; will you allow us to do this for you?
These maintenance visits can inevitably save you future discomfort, extensive and expensive
dental treatment and help preserve your natural teeth for a lifetime. We hope this information
enables you to make a well informed choice about your oral health. Therefore, we are requesting
that you call us at your earliest convenience to schedule your necessary periodontal (bone and
gum tissue) maintenance visit. Remember, our office number is (insert phone number) and our
office hours are (state your hours here). Looking forward to your call.
In the Interest of Better Health,
(Provider’s Name) and Name of Hygienist
©2009 Roz Fulmer, Making a Difference…Today!
46
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Here is a sample for a Hygiene Recall Postcard:
Dear (Patients Name),
Don’t you deserve a nice smile? We know you have a busy schedule, but we are concerned that
you have not had your teeth examined or cleaned, nor have you had an oral cancer screening in
this office since (Date of last hygiene visit). Have you been seen elsewhere?
Wouldn’t you agree that the best dental investment you can make to keep your teeth for a
lifetime is to have a thorough examination, diagnosis, and a cleaning at least every 6 months?
Please call our office at (insert phone number) today for an appointment.
Sincerely,
(Provider’s Name) and Name of Hygienist
©2009 Roz Fulmer, Making a Difference…Today!
47
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is a sample of Final Hygiene Recall Letter or Postcard:
Patient’s Name
Address
City, State, Zip
Dear Bonnie:
We are worried about you! We have sent you several reminders that you were due at our office
for your examination and check up, did you receive any of them? We just want to make sure that
you are receiving professional care for your oral health, are you? Will you please return the
bottom portion of this letter indicating your preference with our office? Thank you in advance
for taking your time and returning the bottom portion with your answer.
Sincerely,
(Provider’s Name) and Name of Hygienist
PLEASE CUT ALONG THIS LINE AND MAIL BOTTOM PORTION BACK
____________________________________________________________________________
Patient’s Name: _____________________________________________________________
______ Oops, I did not realize it was that long. Please call me for an appointment at the
following number________________________________________.
______ Now is not a good time but keep my record active. Call me in a month for an
appointment.
______ Please make my record at your office inactive. Have transferred to another office.
©2009 Roz Fulmer, Making a Difference…Today!
48
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is a sample for a Denture Recare Notice:
Patient’s Name
Address
City, State, Zip
Dear Bonnie:
We are worried about you! We have sent you several reminders that you were due at our office for your
examination, check up for your denture, gum tissue check and a yearly oral cancer screening,, did you
receive any of them? We just want to make sure that you are receiving professional care for your oral
health, are you?
You may be wondering, “Why do I need to see the dentist if I have no teeth?” You may be surprised to
find out that at a preventive heath visit in our office we check more than just teeth! The following is a
partial list of what will be evaluated at your next visit:
Oral cancer screening: Did you know that almost all of oral cancers found in the mouth are found by
dentists? Oral cancer can be one of the most aggressive forms of cancer if not diagnosed and treated
early.
The overall look of your denture: Did you know that a “droopy smile line” can be a sign of the need for
a simple reline to add “vertical dimension” or new height to your face?? A settling denture will cause
your chin to approach your nose at a rate of as much as 1/16th of an inch per year! Have you noticed a
change in your profile?
The fit of your denture: Did you know that an ill-fitting denture can open the door to infections like
Candida and speed up the loss of bone in the face? This is a very special oral health concern for denture
wearers and the concerns are a fungus that attacks the lining of your dentures if ill-fitted, are your
dentures getting loose yet?
The way your dentures come together (your bite): Did you know as your bone shrinks, the changes in
the way your dentures fit can affect the way they come together? Dentures that fit well together enable
you to enjoy more whole foods. They will also last longer. It is similar to the way balanced tires wear
evenly.
Doesn’t it make sense to have an annual check up to have the peace of mind that you do not have Oral
Cancer, or this infection in your gum tissue?
Will you call our office at (insert phone number) today for an appointment so we can take care of you?
Sincerely,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
49
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is a sample for a Patient Reactivation Letter:
To: Our Dental Family Members:
When was the last time you heard your dentist say “IT’S FREE?”
Well, until (give a deadline date), any patient who has not been in our office for a year or more is
invited to come and visit our office for a complete dental examination and necessary x-rays at
NO CHARGE, YES NO CHARGE!
If you know of anyone who has felt that the initial consultation and examination costs were the
barrier to receiving the benefits of proper dental care, now is the PERFECT time to extend this
invitation to them, wouldn’t you agree? Please feel free to give them this invitation or come with
you should you both want to use this great offer as we would love to help you both, isn’t that
wonderful?
To better accommodate you, our office hours are listed below:
Monday – Thursday---7:00 am to 6:00 pm
Tuesday – Wednesday ---7:00 am to 4:00 pm
Our phone number is: (list your phone number)
When calling, please be sure to mention this invitation. This offer is good only through (give a
deadline date), so don’t wait as the schedule is filling fast and we want to help you get what you
want for your oral health.
With your dental health in mind,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
50
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Here is a sample for a Denture Recare Notice:
Patient’s Name
Address
City, State, Zip
Dear (Patient’s Name),
We are worried about you! Do you remember that we are located at 666 E Main Street? Your
name appeared on our previous patient recare list. Dr. (Provider’s Name) and his/her team are
concerned about your overall oral health. We just want to make sure that you are receiving
professional care for your oral health, are you? If not, please feel free to call our office today at
555-5555 to schedule an appointment. WE would be glad to see you again!
Don’t wait until something hurts! Are you aware that periodontal (gum) disease is painless? It
affects 90% of the population and often patients are unaware that they have it. The World Health
Organization now recognizes the correlation between oral diseases and other systemic problems
such as heart, kidney and liver diseases. Don’t you owe it to yourself to act now? Isn’t keeping
your teeth and body strong and healthy for your lifetime important to you?
Did you know that your smile is one of the most important aspects of your personality?
Our office hours are Monday – Thursday 8am – 5pm. Will you let us help you maintain your
oral health? Call our office today (insert phone number) for an examination and hygiene
appointment?
Sincerely,
(Providers Name) and his/her Dental Team
©2009 Roz Fulmer, Making a Difference…Today!
51
_____________________________________________________________________________
Here’s how for…..
Release forms for
Photo & Model
Patient Records
Treatment Refusals
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Photo and Model Release Letter
Patient’s Name
Address
City, State, Zip
SIMPLIFIED ADULT RELEASE:
For valuable consideration received, I, Model name hereby give (Practice Name) the absolute
and irrevocable right and permission, with respect to the photographs that have been taken of me
to be used and republished for any commercial use for the territory of the whole world.
A. To copyright the same in its own name or any other name that (PRACTICE NAME), Inc.
may choose.
B. To use, re-use, publish and re-publish the same in whole or in part, individually or in
conjunction with other photographs, in any medium and for any purpose whatsoever,
including (but not by the way of limitation) illustration, promotion and advertising and
trade through December 31, 2099.
C. This authorization and release shall also apply to the benefit of the legal representatives,
licensees and assigns of (DENTAL PRACTICE NAME), Inc.
I am over the age of eighteen. I have read the foregoing and fully understand the terms of this
release.
Name: ____________________________ Phone Number: ______________________________
Address: __________________________ City, ___________________ State,______Zip ______
Date ______________________________ Signed: _____________________________________
Date: _____________________________ Witnessed by: ________________________________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
Photo Release Form
Name of Patient
Date:
Address
C/S/Z
Dear (Name of Patient),
I am please you have agreed to be featured in my __________________________ (if photo)
showing off your beautiful smile. My office will pay for all fees associated with your photograph
and supply you with a copy of the photo and the publication. Please read and sign below as
consent to use your photo and text regarding your dental experience.
Patient Signature: __________________________________ Date: ____________
My signature above gives permission to (tell my dental story; use my testimonial; reprint my
letter). I understand my photo and text will be included in ____________________________
being published by Dr.__________________. These materials may be used in future publication,
website and/or advertisements for which I also give my permission until 2099.
Thank you for allowing me the pleasure of providing you with your dental care. I am proud to be
a part of your success. I look forward to many years as your dentist.
_________________________________________________ Date: ____________
Patient’s Signature
_________________________________________________ Date: ____________
Doctor’s Signature
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Photo Release Form
I hereby grant permission to Dr. (Name of Practice) to use my photograph on its World Wide
Web site or in other official printed publications dental or otherwise without further
consideration or until December 31, 2099. I acknowledge Dr. (Name of Practice) the rights to
crop or treat the photograph at its discretion. I also acknowledge that Dr. (Name of Practice) may
choose not to use my photo at this time, but may do so at his/her own discretion at a later date. I
also understand that once my image is posted on Dr. (Name of Practice) website, the image can
be downloaded by any computer user. Therefore, I agree to indemnify and hold harmless from
any claims that may incur with Dr. (Name of Practice).
Dr. (Name of Practice) reserves the right to discontinue use of photos without notice.
I am over the age of eighteen. I have read the foregoing and fully understand the terms of this
release.
Name: ____________________________ Phone Number: ______________________________
Address: __________________________ City, ___________________ State,______Zip ______
Date ______________________________ Signed: _____________________________________
Date: _____________________________ Witnessed by: ________________________________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
PHOTO CONSENT FORM
Dr. (Name of Practice) often takes photographs or video film for publicity purposes. These
images may appear in our printed publications, on our website, or within our lectures. They may
also be sent to the news media as well. Before taking any pictures, we need your permission.
Please answer Yes or No to the following questions below, then sign and date the form where
shown.
Please circle Yes or No
1 May we use your image(s), or those of your child(ren) if under 18, in publicity material
produced by Dr. (Name of Practice), including printed publications, videos and our website until
December 31st, 2099?
Yes / No
2 We regularly send publicity material about our services, including photographs where
appropriate, to the news media, especially the local press. Can we use your photograph, or your
child's until December 31st, 2099?, in this way?
Yes / No
Please note that websites can be viewed throughout the world, not just in the United States where
USA law applies. This form is valid till 2099.
Signature: ______________________________ Date: ____________________
Witness: _______________________________ Date: ____________________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Release of Records
I, ____________________ hereby authorize Dr. (Provider’s Name) to release my (Print
Patient’s Name) dental records. These records may include x-rays, treatment notes,
charting, medical and dental history, photographs, or other notations relevant to my
treatment.
These records may be released to: (Circle One)
1. My dentist / doctor:
________________________________
Address:
________________________________
Phone number:
________________________________
2. Send to my home Address:
3. Released to person authorized by me to be picked up at your office:
I will personally pick up records today.
____________________________________
Patient’s Signature
©2009 Roz Fulmer, Making a Difference…Today!
___________
Date
57
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Release of Records
AUTHORIZATION FOR RELEASE OF INFORMATION
AND HEALTH RECORDS
To: ______________________________________________
From:(Patient’s Name): ______________________________
I hereby request and authorize (Provider’s Name) and/or his/her employees to furnish to my new
dental home and/or anyone designated by him/her, all records, including radiographs (x-rays)
and photo static copies, abstracts or excerpts from all records and other information you may
possess relating to any examination, treatment or opinion concerning any condition that I or any
member of my family may have had in the past, now have, or may have in the future. Your
assistance and cooperation is greatly appreciated.
I hereby revoke all previous authorizations given by me for the release of dental or medical
information for any reason or purpose whatsoever, and do specifically request that no dental or
medical information of any nature be given out at any time to any insurance Practice, their
attorney or anyone else representing them without my authorization.
Signed: _____________________________________ Date: ______________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
REFUSAL OF X-RAYS
Patient Name: ____________________________________________________
I have voluntarily chosen to refuse diagnostic x-rays to help with the diagnosis and/or treatment
planning of my dental condition as recommended by Dr. I (Provider’s Name). It has been
explained to me the need for x-rays, and I will not hold Dr. (Provider’s Name) liable for any
failure to diagnose or provide treatment, which may result from my decision. I assume full
responsibility for any conditions relating to my dental health that might be the result of this
decision due to the lack of radiographs.
Patient Signature__________________________________________________
Witness_________________________________________________________
Date of Signatures: ________________________________________________
©2009 Roz Fulmer, Making a Difference…Today!
59
_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Discussion and Refusal of Treatment
Patient’s Name_____________________________________ Date of Birth___________
I am being provided this information and refusal form so I may fully understand the treatment recommended for me
and the consequences of my refusal. I want to be provided with enough information, in a way I can understand, to
make a well informed decision regarding my proposed treatment.
I understand that I may ask any questions I wish regarding the recommended treatment.
Nature Of The Recommended Treatment
It has been recommended that I have the following treatment: ______________________
This recommendation is based on visual examination(s), on any x-rays, models, photos and other diagnostic tests
taken, and on my doctor’s knowledge of my medical and dental history. The treatment is necessary because of:
____Decay ___Broken tooth/teeth ___ Infection
____Pain
____Periodontal (gum) disease ___Other____________________________________________
The prognosis, or chance of success, of this treatment is:
____Good ____Fair ____Poor _____Guarded _____Hopeless
The recommended treatment is estimated to take____ visits to complete.
The estimated cost for the treatment is $_______________.
I have had an opportunity to ask questions about this recommended treatment and any other alternatives. I still elect
to do NO treatment at this time. I understand that no dental treatment is completely risk free and that my dentist
would take reasonable steps to limit any complications of my treatment.
Risks Of Not Having The Recommended Treatment
I understand that complications to my teeth, mouth, and/or general health may occur if I do not proceed with the
recommended treatment. These complications include but are not limited to: Loss of tooth/teeth, infection, pain,
decay and tooth fracture.
I do NOT wish to proceed with the recommended treatment.
Signed:________________________________________________ Date:_________________
Patient or Guardian
Signed:________________________________________________ Date:_________________
Treating Dentist
Signed:________________________________________________ Date:__________________
Witness
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Refusal Of Periodontal Charting
Patient Name: _____________________________________ Date of Birth: ______________
I have voluntarily chosen to refuse (not have) my gums charted to check my periodontal status
(the health of my gums). I understand this is important in the diagnosis and /or treatment
planning of my dental health. I have been explained the need for the periodontal charting and I
will not hold Dr. (Provider’s Name) and / or any of his employees liable for the failure to
diagnose or provide treatment, which may result from my decision. I assume full responsibility
for any condition relating to my dental health that might be the result of this decision. I fully
under-stand that I may loose my teeth if I have periodontal disease and it goes untreated because
it could not be diagnose due to not having any periodontal charting.
Patient Signature: ___________________________________________________________
Witness: __________________________________________________________________
Date of Signatures: __________________________________________________________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
DIAGNOSED AND RECOMMENDED
PERIODONTAL THERAPY
REFUSAL FORM
NAME _________________________ CASE TYPE _______________
I have been advised and diagnosed with Case Type _____ Periodontal (Gum) Infection. The
severity of my periodontal (gum) infection, its nature and cause, and recommended therapy has
been thoroughly explained to me and I understand the severity of my condition. At this time, it
is my choice not to follow through with the recommended non-surgical therapy. I have also been
informed of the services of a gum specialist, the Periodontist. I choose at this time not to engage
in either the non-surgical therapy or Doctor (Provider’s Name), or consult with a Periodontist. I
further understand that by refusing this treatment of my disease, I may lose some or all of
my teeth, my teeth may become loose and I understand that I may lose bone due to this
infection.
PATIENT SIGNATURE _____________________ DATE __________
DOCTOR SIGNATURE _____________________ DATE __________
WITNESS SIGNATURE_____________________ DATE __________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Here are
Consent Forms
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
(Insert Today’s Date)
Patient’s Name
Address
City, State, Zip
Consent for Dental Treatment
Patient Name:________________________________________ Date: ____________________
I hereby consent to the following described dental procedures upon me by or under the direction of Dr.
(Provider’s Name), his associates and assistants. In the event that Dr. (Provider’s Name) becomes
unavailable, I authorize him to select a replacement to accomplish the agreed upon procedures without
delay.
I acknowledge that the following information has been provided to me.
Nature of my dental illness: Periodontal Disease, Abscessed tooth, Cracked Broken tooth, Teeth
with failing restorations, Unrestorable teeth, Decayed teeth, Missing teeth, Posterior (back) bite
collapse, Bite Problems, other _________________________________________. The purpose of the
following procedure is to correct, restore or improve the above conditions.
Treatments: I understand that I am having the following dental treatment done: (please read and initial
the items checked below)
1. Anesthesia and medications I consent to administrations of local anesthesia and other drugs deemed
necessary in my case and understand the risks of reactions, such as redness, swelling, pain, itching,
vomiting, anaphylactic shock and for permanent nerve damage or other unforeseeable complications
which may result from the administration of my drug or anesthetic.
Initials:
2. Periodontal therapy (Periodontics) I understand that I have a serious condition causing gum and
bone infection or loss that can lead to the loss of my teeth. Alternative treatment has been explained to me
including gum surgery, tooth replacements and/or extractions. I understand that not undertaking any
dental procedure may have a future adverse effect on my periodontal condition.
Initials:
3. Root Canals (Endodontics) and Posts I realize there is no guarantee that root canal therapy and posts
will save my tooth, and that complications can occur from the treatment. Complications can include
breakage of metal objects in the tooth and over extension of cement or filling materials outside the root tip
that may result in permanent nerve damage. I understand that further understand that although rare,
perforations (going out the side of the tooth) can occur. I am also aware that, after root canal therapy a
crown or onlay will need to be placed on the tooth.
Initials:
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
4. Tooth and tissue removal (Oral surgery)
Alternative to removal have been explained to (root canals, crowns, and periodontal surgery, etc) and I
authorize Dr. (Provider’s Name), his associates and assistants to remove the following teeth and any other
necessary for reasons described in the first paragraph above (nature of my dental illness). I under-stand
that removing teeth does not always remove all the infection and if infection remains it may be necessary
to have further treatment. I understand the risks involved in removing my tooth/teeth some of which are
pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue, and surrounding
tissue (paresthesia) that can last an indefinite amount of time and/or a fractured jaw. I understand I may
need further treatment by a specialist or even hospitalization for complications, which may arise during,
or following treatment, the cost of which is my responsibility. I understand that tooth replacement will be
necessary soon after the removal of my teeth. (Except wisdom teeth (3rd molars).
Initials:
5. Tooth Colored Fillings (composites)
I understand that my teeth need new or replacement fillings. Certain side effects can include hot, cold,
and/or biting sensitivity (pressure). With larger cavities, root canals and/or crowns may be necessary to
stabilize my tooth/teeth. (Occasionally a "high spot" in your bite may develop after the numbness has
worn off. If this occurs please contact our office immediately for an adjustment of the" high spots"). I
understand it is sometimes not possible to match the color of natural teeth exactly with artificial filling
materials.
Initials:
6. Tooth Colored/Gold Crowns and Bridges
I understand that I may be wearing temporary crowns or bridges, which may come off easily, and that I
must be careful to ensure they are kept in place until the custom crown or bridges are placed. I further
understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth.
I understand the final opportunity to make changes in my new crowns/bridges color, shape, fit or size
before cementation. I realize that some crowns and bridges are used to treat decay and fracture and
therefore may require root canal therapy during or after treatment if symptoms arise.
Initials:
7. Partial and Complete Dentures
I realize that complete or partial dentures are artificial and are constructed of plastic, metal and/or
porcelain. The problems in wearing these appliances have been explained to me, include looseness, soreness, and possible breakage. I realize that the final opportunity to make changes in my new dentures
(including fit, size, placement, and color) will be the "Teeth in Wax" visit. I understand that most dentures
require relining approximately three to twelve months after initial placement. The cost of this procedure is
not included in the initial denture fee. I also understand that all adjustments are included for one month
following the placement of the denture. Any future adjustment will have a fee.
Initials:
8. Financial Responsibility
I understand that Dr. (Provider’s Name) and his staff feel that dental treatment is an excellent investment
in an individual's medical and psychological well-being and financial considerations should not be an
obstacle to obtaining this important health service. In their efforts to make their services more affordable
for the patients, they have several forms of payment. Regardless of method of payment I agree to
unconditionally pay for services rendered, irrespective of payment by insurance carriers, workers
compensation and the like. I also agree to pay for services when they are rendered unless other
arrangements have been made with the financial coordinator. I understand that financial changes will be
added to my account for delinquent payments at the rate of one and one-half percent per month on the
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
total balance. I further agree to pay for attorney's fees and collection costs in the event I fail to pay or my
insurance fails to pay my account in full within 90+ days of receipt of services.
I further consent to the admission of observers into the procedure for the purpose of medical education or
science. I further agree that photographs may be taken of me during the procedure and that the
photographs and a narrative of my case may be used for medical education of science, including
publication in professional journals and medical books. I consent to the performance of operations and
procedures in addition to or different from those above contemplated which Dr. (Provider’s Name) or his
associates and assistants consider therapeutically necessary even though this procedure may be an
emergency. I understand that the extension of this procedure may include risks not previously discussed
but, nevertheless, grant to Dr. (Provider’s Name), his associates and assistants, the authority to proceed
with such additional procedures. I further consent to the disposal of tissue or parts removed at the time of
the operation. I realize that it is mandatory that I give as accurate and complete medical and personal
history as possible and that I have done so. I further agree to follow any and all instructions as directed
and permit prescribed diagnostic procedures. I understand that there can be no guarantee of outcome with
my dental procedure and acknowledge no guarantee has been made to me with regard to the procedures I
have requested authorized. I further acknowledge that I have been given full opportunity to discuss the
matters contained herein with Dr. (Provider’s Name), his associates or assistants and that I understand the
information provided.
Patient’s Signature: ______________________________________________Date: ______________
Witness: _______________________________________________________Date: ______________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
Full name of patient
Date
Address
C/S/Z
CONSENT FOR EXTRACTION OF TEETH/ORAL SURGERY
Extraction of teeth is an irreversible process and, whether routine or difficult, is a surgical procedure. As
in any surgery, there are some risks. They include, but are not limited to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Swelling and/or bruising and discomfort in the surgery area.
Stretching of the corners of the mouth resulting in cracking and bruising.
Possible infection requiring further treatment.
Dry socket – jaw pain beginning a few days after surgery, usually requiring additional care. It is
more common from lower extractions, especially wisdom teeth.
Possible damage to adjacent teeth, especially those with large fillings.
Numbness or altered sensation in the teeth, lip tongue and chin, due to the closeness of tooth roots
(especially wisdom teeth) to the nerves which can be bruised or injured. Sensation most often
returns to normal, but in rare cases, the loss may be permanent.
Trismus – limited jaw opening due to inflammation or swelling, most common after wisdom
tooth removal. Sometimes it is the result of jaw joint discomfort (TMJ), especially when TMJ
disease and sym-toms already exist.
Bleeding – significant bleeding is not common, but persistent oozing can be expected for several
hours.
Sharp ridges or bone splinters may form later at the edge of the socket. These may require
another surgery to smooth or remove them.
Incomplete removal of tooth fragments – to avoid injury to vital structures such as nerves or
sinuses, sometimes small root tips may be left in place. Sinus involvement: the roots of upper
back teeth are often close to the sinus and sometimes a piece of root can be displaced into the
sinus, or an opening may occur into the mouth which may require additional care.
Jaw fracture – while quite rare, it is possible in difficult or deeply impacted teeth. Most
procedures are routine and serious complications are not expected. Those which do occur are
most often minor and can be treated.
Teeth to be removed: _________________
I understand the doctor may discover other or different conditions that may require additional or different
procedures from those planned. I authorize such other procedures as are deemed necessary in my
doctor’s professional judgment to complete my surgery.
I have read and understand the above, and have had my questions answered. I recognize there can be no
warranty as to the outcome of treatment, and I give my consent to surgery.
Patient’s (or Legal Guardian’s) Signature: _______________________________ Date: ____________
Doctor’s Signature: _________________________________________________ Date: ____________
Witness’ Signature: _________________________________________________ Date: ____________
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
Here is a Sample of Letter to Patient who will have Immediate Dentures
placed, give this to patient PRIOR to actual treatment.
After the Removal of Multiple Teeth plus Placing of Immediate Denture:

A small amount of bleeding is to be expected following the operation. If bleeding occurs, place a gauze pad
directly over the bleeding socket and apply biting pressure for 30 minutes. If bleeding continues, a moist
tea bag can be used for 30 minutes. If bleeding occurs, avoid hot liquids, exercise, and elevation the head.
If bleeding persists, call our office immediately. Do not remove immediate denture unless the bleeding

is severe. Expect some oozing around the side of the denture.
Use ice packs (externally) on the same side of the face as the operated area. Apply ice for the first 36 hours
only. Apply ice continuously while you are awake.

For mild discomfort use aspirin, Tylenol or any similar medication; two tablets every 3-4 hours. Ibuprofen
(Advil, Motrin) 200mg can be taken 2-3 tablets every 3-4 hours.

For severe pain use the prescription given to you. If the pain does not begin to subside in 2 days, or
increases after 2 days, please call our office. If an antibiotic has been prescribed, finish your prescription
regardless of your symptoms.

Drink plenty of fluids. If many teeth have been extracted, the blood lost at this time needs to be replaced.
Drink at least six glasses of liquid the first day.

Do not rinse your mouth for the first post-operative day, or while there is bleeding. After the first day, use a
warm salt water rinse every 4 hours and following meals to flush out particles of food and debris that may
lodge in the operated area. (One half teaspoon of salt in a glass of lukewarm water.). After you have seen
your dentist for denture adjustment, take out denture and rinse 3 to 4 times a day.

Restrict your diet to liquids and soft foods, which are comfortable for you to eat. As the wounds heal, you
will be able to advance your diet.

The removal of many teeth at one time is quite different than the extraction of one or two teeth. Because the
bone must be shaped and smoothed prior to the insertion of a denture, the following conditions may occur,
all of which are considered normal:
 The area operated on will swell reaching a maximum in two days. Swelling and discoloration around the
eye may occur. The application of a moist warm towel will help eliminate the discoloration quicker. The towel
should be applied continuously for as long as tolerable beginning 36 hours after surgery (remember ice packs
are used for the first 36 hours only).
 A sore throat may develop. The muscles of the throat are near the extraction sites. Swelling into the throat
muscles can cause pain. This is normal and should subside in 2-3 days.
 If the corners of the mouth are stretched, they may dry out and crack. Your lips should be kept moist with
an ointment like Vaseline. There may be a slight elevation of temperature for 24-48 hours. If temperature
continues, notify our office.
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 Immediate dentures have been inserted, sore spots may develop. In most cases, your dentist will see
you within 24-48 hours after surgery and make the necessary adjustments to relieve those sore spots.
Failure to do so may result in severe denture sores, which may prolong the healing process.
 NOTE: Immediate Dentures mean just that immediate! This means that they are ONLY temporary
and will need to be relined and/or adjustments made several times over the next 6-8 months as needed
due to the bone structure shrinkage. FINAL dentures will be made and placed after 6-8 months
depending on healing and bone shrinkage.
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
ROOT CANAL CONSENT FORM
1. Root canal therapy is about 95 percent successful. Many factors influence the treatment
outcome: the patient's general health, bone support around the tooth, strength of the tooth
including possible fracture lines, shape and condition of the root and nerve canal(s), etc.
2. The tooth may normally be sensitive following appointments and even remain tender
for a time after treatment is completed. If sensitivity persists, and does not seem to be
getting better, even several weeks after the root canal is finished, please let the doctor know.
3. Fractures are one of the main reasons why root canals fail. Unfortunately, some cracks
that extend from the crown down into the root are invisible and hard to detect. They can
occur on uncrowned teeth from traumatic injury, biting on hard objects, habitual clenching or
grinding, or even just normal wear and tear. Whether the fracture occurs before or after the
root canal, it may require extraction of the tooth.
4. Since teeth with root canals are more brittle than other teeth, the dentist will probably
recommend a crown to prevent future damage. This is especially important with molar
and bicuspid teeth.
5. With some teeth, conventional root canal therapy alone may not be sufficient. For
example, if the canal(s) are severely bent or calcified, if there is substantial or longstanding
infection in the bone around the roots, or if a metal file becomes separated within a canal, the
tooth many remain sensitive and a surgery procedure may be necessary to resolve the
problem.
6. There are alternatives to root canal therapy. They include no treatment at all, extraction
with nothing to fill the space, and extraction followed by a bridge, partial denture, or implant
to fill the space.
7. Teeth treated with root canals must be protected during treatment. Between
appointments, your tooth will have a temporary cement filling. If this should come out,
please call the office and arrange to have it replaced.
After the root canal is completed, an additional procedure to place a permanent restoration,
usually a crown will be required. Failure to follow through with a permanent restoration may
result in: infection, pain, the need to retreat the root canal, or the loss of the tooth.
The nature of root canal therapy has been explained to me and I have had a chance to have my
questions answered. I understand that dentistry is not an exact science and success with root
canals cannot be guaranteed. In light of the above information, I authorize the doctor to
proceed with treatment.
___________________________________________________________________________
Patient/Guardian (if patient is a minor) Signature:
Witness: ___________________________________________________________________
Doctor Signature: __________________________________________ Date: _____________
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Your Letterhead
REQUEST FOR ANESTHESIA AND SEDATION
It is our moral and legal obligation to give you the information necessary to make an educated decision in
requesting treatment. The benefits of therapy are usually greater than the risk, but just as there are risks
involved with driving a car, there are events that can occur with any type of treatment. These are being
explained to inform and educate you... not to alarm you. Eliminating surprises will make your care go more
smoothly.
Routine Aftermath. . .
1. Minor oozing of blood from the surgery sites, if your are having teeth extracted, which will require you to
use gauze pressure packs for the first 24 to 36 hours.
2. Post operative discomfort and swelling, which may require several days of home recuperation.
3. Chapping of the lips caused by stretching the comers of the mouth during surgery.
4. Stiffness of the jaws and restricted mouth opening from several days to several weeks depending on the
extent of the treatment.
Rare occurrences... can include any event that might be remotely possible but unlikely to occur. People rarely
plan their lives around these, but are still aware that they can occur. These include: allergic reaction to drugs
which range from hives to heart failure. Many drug reactions are side effects and treated as such. The office
staff has had training in managing these potential problems.
-Medication, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and
coordination, which can be increased by the use of alcohol or other drugs. It would be wise not to operate any
vehicle, automobile or hazardous device while taking such medication and/or drugs. Your judgment and work
performance can be altered by pain medication or the sedative agents and you should plan accordingly.
-Your signature below certifies -Your consent and request (name of Dentist) D.D:S. or any dentist working
with him to perform the following treatment procedure or surgery...
Full treatment as described in my treatment plan:
- Your understanding that on rare occasions, individual patient differences can result in relapse of a condition
in spite of our efforts to provide optimum care. In this event you understand that selective re-treatment maybe
necessary.
-Your agreement to the administration of anesthesia, nitrous oxide/oxygen and/or oral sedation as discussed
with (name of Dentist), D.D.S. \
-Your authorization for (name of Dentist) to use his best judgment in managing unforeseen conditions, which
might unexpectedly arise, during the course of the procedure.
- Y our understanding that lack of cooperation with our recommendations during your care may result in less
than optimum result.
-That you read and write English, understand the above information and have the opportunity to review and
discuss it as well as your health history including any serious problems or injuries.
- That all statements requiring insertion or completion were fined in and inapplicable paragraphs, if any, were
stricken before you signed...
-That you are both mentally and physically competent to give this consent.
Patient, Parent, or Guardian: ______________________________________ Date: __________
Doctor: _______________________________________________________ Date: __________
Witness: _______________________________________________________ Date:__________
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Your Letterhead
Crown & Veneer Consent Form
Treatment involves restoring damaged areas of the tooth above and below the gum-line with a crown
Restoration of a tooth with a crown requires two phases: 1) preparation of the tooth, an impression to send
to the lab, and construction and temporary cementation of a temporary crown; and later, 2) removal of the
temporary crown, adjustment and cementation of the completed crown when esthetics and function have
been verified.
Approximate Cost will be: _____________
Once a temporary crown has been placed, it is essential to return to have the new crown placed as soon as
it is ready because the temporary crown is not intended to function as well as the permanent crown.
Failing to replace the temporary crown with a completed one could lead to decay, gum disease, infections,
problems with your bite, and even loss of the tooth.
Anterior (front tooth) veneer treatment involves removing less tooth structure than a crown preparation. It
is irreversible because part of the tooth’s enamel must be removed.
Approximate Cost: _______________________.
Benefits of Crowns and Veneers, Not Limited to the Following:
A crown is typically used to strengthen a tooth damaged by decay, fracture, or previous restorations. It
can also serve to protect a tooth that has had root canal treatment or improve the way your' other teeth fit
together. Crowns and veneers will be used for the purpose of improving the appearance of damaged,
discolored, misshapen, misaligned, or poorly spaced teeth.
Risks of Crowns and Veneers, Not Limited to the Following:
I understand that preparing a damaged tooth may further irritate the nerve tissue (called the pulp) in the
center of the tooth, leaving my tooth feeling sensitive to heat, cold, or pressure. Such sensitive teeth may
require additional treatment including endodontic or root canal treatment. I understand that holding my
mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it
difficult for me to open wide for several days. This can occasionally be an indication of a further problem.
I must notify your office if this or other concerns arise. I understand that a crown or veneer may alter the
way my teeth fit together and may make my jaw joint feel sore. I understand that my speech may sound
like a “lisp” for several days, weeks or months. This may require adjusting my bite by altering the biting
surface of the crown or veneer or adjacent teeth.
I consent to the crown preparation and placement as described above by Dr._______________________________
I consent to the veneer preparation and placement as described above by Dr. ______________________________
Patient’s Signature___________________________________________ Date ____________________________
I attest that I have discussed the risks, benefits, consequences, and alternatives of crowns and veneers with
_____________ (Patient’s Name) who has had the opportunity to ask questions, and I believe my patient
understands what has been explained.
Dentist’s Signature _______________________________________________________ Date ________________
Witness’s Signature _______________________________________________________ Date________________
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DENTAL TREATMENT CONSENT FORM
Please read and sign bottom of form
Patient Name: __________________________
1. WORK TO BE DONE I understand that I am having the following work done:
Fillings________ Bridges________ Crowns________
Extractions________ Root Canals_______
Other_________________________________________________________________________
2. DRUGS AND MEDICATIONS I understand that antibiotics, analgesics and other medications
can cause ALLERGIC reactions causing redness and swelling of tissues, pain, itching,
vomiting, and/or anaphylactic shock (severe allergic reaction), I also understand that
occasionally needles break and may require surgical retrieval by an oral surgeon.
3. CHANGES IN TREATMENT PLAN I understand that during treatment it may be necessary to
change or add procedures because of conditions found while working on the teeth that were
not discovered during examination, the most common being root canal therapy following
routine restorative procedures. I give my per-mission to the Dentist to make any changes and
additions as necessary.
4. REMOVAL OF TEETH Alternatives to removal have been explained to me (root canal therapy,
crowns, and periodontal surgery, etc.) and I authorize the Dentist to remove the following
teeth_________________ and any others necessary for reasons in paragraph #3. I understand
removing teeth does not always remove all the infection, if present, and it may be necessary to have
further treatment. I understand the risks involved in having teeth removed, some of which are
pain, broken roots left in bone, swelling, spread of infection, dry socket, loss of feeling in my
teeth, lips, tongue, and surrounding tissue (Paresthesia) that can last for an indefinite period
of time (days or months) or fractured jaw. I understand I may need further treatment by a
specialist or even hospitalization if complications arise during or following treatment.
5. CROWN, BRIDGES AND CAPS I understand that sometimes it is not possible to match the color &
shape of artificial teeth exactly with natural teeth. I further understand that I may be wearing
temporary crowns, which may come off easily and that I must be careful to ensure that they are kept
on until the permanent crowns are delivered. I realize the final opportunity to make changes in my
new crown; bridge or cap (including shape, fit, size, and color) will be before cementation. I’m
aware that there is no guarantee of the longevity of my Crowns, Bridges, and Caps and that a 12month re-do policy is in effect. A 6-month checkup, which includes a cleaning, is suggested to
ensure that the Crown or Bridge does not develop a cavity or any other complications. If I do not
follow up with a 6-month check-up, Dr. Anthony will not perform a free of charge re-do.
Instead I will be responsible for the cost associated with any complications. If Dr. Anthony
doesn’t feel that the crown fits to his satisfaction at time of delivery a new impression will be
taken which may also include additional tooth shaping & wearing of the temporary crown
until a permanent crown fits. I’m also aware that when cutting teeth there is a chance that the
nerve of the tooth could become injured & that possible root canal therapy would be needed
before or after the crown is delivered. Crowns will normally last up to five years or longer as
long as good oral care is performed daily.
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6. PARTIALS I realize that partial dentures are artificial, constructed of plastic, metal, and/or
porcelain. The problems of wearing these appliances have been explained to me, including
looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my
new partials (including shape, fit, size, placement, and color will be the try-in visit. I understand
that most partials may require relining approximately three to twelve months after initial
placement. The cost for this procedure is not included in the initial denture fee. Also, after the
initial phases of adjustments have been made, any further adjustments will be considered as an
additional fee. I am also aware that partials are a substitute for what is missing and that once
treatment has begun, I will not be refunded for any of the cost if I am not pleased with the
results.
7. ENDODONTIC TREATMENT (ROOT CANAL) I realize there is no guarantee that root canal
treatment will save my tooth, and that complications can occur from the treatment, and that
occasionally metal objects are cemented in the tooth or extended through the root, which does
not necessarily affect the success of the treatment. I understand that occasionally additional
surgical procedures may be necessary following root canal treatment (Apicoectomy), which is
performed by a specialist, which is an additional fee to the patient. I also understand that when
my root canal is started that it needs to be completed within a month to prevent future infection. I
understand that if the root canal is not completed within a specified time (one month) and infection
develops that I will be charged an additional fee for treating the infection.
8. PERIODONTAL LOSS (TISSUE & BONE) I understand that I have a serious condition, causing
gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment
plans have been explained to me, including gum surgery, replacements and/or extractions. I
understand that undertaking any dental procedures may have a future adverse effect on my
periodontal condition. Our office will treat your conditions as deemed necessary. The treatment that
will be performed will consist of scaling and root planing (cleaning below the gums) in the
quadrants that require such treatment based on our diagnosis. We may also prescribe you a mouth
rinse to aid the reduction of the bacteria in the mouth; this will help with your home care. After the
initial deep cleaning you will return within a month for periodontal maintenance, this is not
inclusive of the scaling and root planning fee. If progress is acceptable we will place you on a three
month cleaning pro-gram. If progress is not acceptable, then we will recommend that you follow up
with a periodontist (gum specialist) for further treatment that may include surgery. Any questions
ask the staff. The mouth is broken down into quadrants (there are four total)-top right, bottom
right, top left, bottom left. Fees are based on quadrants that need the deep cleanings from 1-4
quadrants. I understand that dentistry is not an exact science and therefore, reputable
practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance
has been made by anyone regarding the dental treatment, which I have requested and
authorized. I have had the opportunity to read the form and ask questions. My questions have
been answered to my satisfaction. I consent to the proposed treatment.
Signature of Patient __________________________________________________Date ______
Signature of Parent/Guardian, if patient is a minor __________________________Date ______
Witness: ___________________________________________________________Date: ______
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Your Letterhead
Informed Consent Inhalation Sedation
(Nitrous Oxide-Oxygen)
Did you know that we offer our patients a variety of pain relievers and sedatives, according to
each individual's needs and desires?
Were you aware that Novocain (local anesthesia) is designed to eliminate pain, which it does
well? Were you also aware that it does not eliminate the tension and anxiety generally
associated with dental treatment in the minds of many people?
We have an inhalation sedative available. It is breathed in along with oxygen from a nosepiece. It
gives you a relaxed, detached feeling; free of tension and anxiety. You will not go to sleep, but
will remain awake and cooperative. After your treatment is completed you will breathe plain
oxygen for several minutes until the effects of the sedative are gone. This sedative does not take
the place of Novocain, but is used along with it. It is in no way compulsory and you may request
only Novocain if you wish.
Some patients experience certain effects while receiving Nitrous Oxide-Oxygen sedation. These
may be, but are not limited to:
a. Excessive perspiration: The peripheral blood vessels enlarge somewhat during sedation
and may cause this.
b. Shivering, especially after sedation, may also be attributed to the dilation of the blood
vessels.
c. Nausea - very few people experience slight nausea. If this happens to you, simply
mention it to any staff member. Breathing pure oxygen can eliminate this quickly.
I understand this sedative procedure and realize that it is purely elective on my part. Any fee(s)
involved have also been explained to me.
Patient Signature _______________________________________ Date __________
Witness: _____________________________________________ Date: __________
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Here are
Hiring and Firing
Documents & Forms
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Your Letterhead
Interview Assessment Checklist
Applicant Name ______________________________ Date of Interview __________________
Interviewed by (doctor) _____________________________Full or Part time position ________
Days/Hours available ___________________________________________________________
Date available for working interview ______________Date available to begin work _________
Salary requirements ______________Benefit requirements _____________________________
Other requirements or wishes expressed by applicant __________________________________
Interview data:
Meets educational requirements
YES
NO
Meets licensure requirements
YES
NO
Meets experience requirements
YES
NO
Discussed practice philosophy
YES
NO
Applicant signed authorization for background check
YES
NO
Proper documentation brought or sent for interview
YES
NO
Proper attire worn to interview
YES
NO
Appropriate communication during interview
YES
NO
Arrived for interview on time
YES
NO
NA
Additional comments:
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
EMPLOYMENT APPLICATION QUESTIONAIRE
Name:_______________________________________________ Date: ___________________
Address:
_____________________________________________________________________________
E-mail address: ________________________________________________________________
Phone number that we can personally contact you at? __________________________________
Desired Position: __________________________ Salary Desired: _______________________
1) What are your expectations if you were to be offered this position?
2) Briefly describe the worst work challenge you have experienced and how did you handle it.
3) If you were out of the office for several days, what would you do when you returned to your
position?
4) What would your last employer or co-workers say was your best quality? Would you agree
with them?
5) What would they ask you to improve and why?
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EMPLOYMENT HISTORY: (START FROM PRESENT OR LAST
POSITION)
Employer: ______________________________ Position Held: __________________________
Address:______________________________________________________________________
Phone Number: __________________________ From: _______________ To ______________
Reason for Leaving: ____________________________________________________________
Employer: ______________________________ Position Held: __________________________
Address: ______________________________________________________________________
Phone Number: __________________________ From: _______________ To ______________
Reason for Leaving: ____________________________________________________________
Employer: ______________________________ Position Held: __________________________
Address: ______________________________________________________________________
Phone Number: __________________________ From: _______________ To ______________
Reason for Leaving: ____________________________________________________________
Employer: ______________________________ Position Held: __________________________
Address: ______________________________________________________________________
Phone Number: __________________________ From: _______________ To ______________
Reason for Leaving: ____________________________________________________________
©2009 Roz Fulmer, Making a Difference…Today!
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3-5 REFERENCES: EXCLUDE RELATIVES
Name/Title
Address & Phone Number
Relationship to you
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
REFERENCE RELEASE
(“the Company/Practice”)
I authorize
or its representatives to provide any and all information concerning my former employment.

Dates of employment
□
Confirm salary information

Reason for employment separation
□
Job title

Quality of performance
□
Attendance and punctuality

Other (describe)
Further, I release all parties from any and all liability for any damages that may result from furnishing
such information to a potential employer, as well as from the use or disclosure of such information by the
Company, or any of its agents, employees, or representatives.
This release is in effect until I rescind it, in writing, and notify the Practice.
Signed:
Date: ___________
Print Name:
Witness Signature: ________________________________
©2009 Roz Fulmer, Making a Difference…Today!
Date: ___________
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Your Letterhead
TERMINATION CHECKLIST
Terminated Employee: ________________________________ Date: __________________
Final Paycheck -- includes all wages and unused accrued vacation
Final Paycheck Acknowledgment
Take all personal property at time of termination, otherwise, a phone call must be made
to retrieve any property that is owned by employee. No other team member is to take out
of the office any remaining employee’s property to be given to the terminated employee.
Return of Company Property:
ALL Keys that are the sole property of the practice
ALL property items that are the ownership of the practice
Credit cards
Post office box keys
Pagers
Cellular phones
Computers and all passwords, codes, usernames
Tools of any kind
Safety equipment
All other materials (e.g., in written or CD, disk form) as requested
401(k) Termination / Rollover information
COBRA information (if applicable)
Other:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Your Letterhead
SAMPLE TERMINATION LETTER
(Date)
(Name of Employee)
(Address of Employee)
Dear (name of employee):
This is to inform you that your employment with _______________ (practice name) will be/is
terminated effective
(date).
Your final paycheck is attached along with an accounting of each item added or deducted.
(STATE CAUSE FOR TERMINATION) Example: Because your tardiness is unacceptable for
the past 4 weeks and after you received three verbal and written warnings, your position has been
terminated.)
Also, we request the immediate return of property and keys, including any and all documents,
passwords or other materials that are in your possession. In addition, there are a number of forms
that require your attention. Other forms, such as COBRA information, will be sent to you and
any eligible dependents, under separate cover.
We wish you well in your future endeavors.
Sincerely,
I understand and accept that my employment with _____________ (practice name) is terminated
effective
and have received my final paycheck and other forms as required.
I have returned all Practice property issued to me or made arrangements to do so.
Signature
©2009 Roz Fulmer, Making a Difference…Today!
Date
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Your Letterhead
SAMPLE FINAL PAYCHECK ACKNOWLEDGMENT
I,
, have received my final paycheck from
. The total amount of the paycheck is $
.
This amount represents:
Wages
$______________
Accrued Unused Vacation
$__________
Other
$__________
$__________
Deductions:
$__________
$__________
$
To the best of my knowledge, there is no additional money owed to me by the Practice and/or
Dr. (Name of Provider) at this present time.
__________________
Date
Signature of Recipient
Signature of Person Issuing Final Check
©2009 Roz Fulmer, Making a Difference…Today!
Date
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Your Letterhead
SAMPLE EXIT INTERVIEW LETTER
Name
Date:___________________
Why are you leaving the office? (If being terminated, you may wish to rephrase this question
and ask, "What is your understanding of why you are being terminated?")
What did you enjoy most about working here?
What did you enjoy least?
What would you have changed about the office/practice to make it a better place to work?
Do you think the compensation you received is competitive with what others doing the
same or similar jobs in other offices/practices receive?
Other comments:
Signature of Employee: ________________________________ Date: ___________
Signature of Doctor: ___________________________________ Date: ___________
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Your Letterhead
Here is a Sample of Job Abandonment: Employee No-Show
SEND THIS LETTER CERTIFIED WITH RECIEPT
SAMPLE JOB ABANDONMENT LETTER
Date
Name of Employee
Address
Dear
This is to advise you that your employment with (name of Practice) is terminated as of today due
to job abandonment.
According to our Employee Handbook, pages ___, if an employee does not report to work,
abuses any form of cell phone usage, internet usage, and personal issues on office time or
violates workplace attendance and punctuality, that employee is considered to have voluntarily
resigned.
Enclosed is your final paycheck which includes payment for all hours worked, plus overtime if
applicable and any earned but unused vacation. This represents all monies owed to you.
Please understand that a voluntary resignation such as this does not entitle you to collect
Unemployment Insurance.
Sincerely,
Name of Provider
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Sample for Time Off Request Form
Employee Name
Number of Days
Start Date
Vacation
Return Date
Type of Leave
Illness
______
Jury Duty
Bereavement
Medical Leave
Personal
Pregnancy Disability Leave
Military Leave
Other
1. Please complete this form in full.
2. Submit it to your direct supervisor for approval.
3. Turn in completed form to (state Provider’s name).
Approvals
____________
Employee’s Signature
Date
Doctor’s Signature
Date
 Copy to doctor/practice
 Copy filed in employee’s file
 Copy to Payroll
 Copy to employee
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Your Letterhead
Your Letterhead
Here is a Sample of Authorization and Release of Information for Potential Employment:
(Insert Today’s Date)
Potential Employee’s Name
Address
City, State, Zip
SAMPLE AUTHORIZATION AND RELEASE
I hereby authorize (Practice) to obtain motor vehicle reports in conjunction with my
application for employment and/or as a condition of my continued employment.
Also, as (Practice’s) agent, I give permission to their insurance broker or insurance
Practice to obtain my driving records and determine my insurability under the Practice’s
insurance coverage.
By signing this disclosure, I am granting that I understand and agree to the Practice’s
request to obtain this information as it is for business-related purposes.
____________________________________
Signature of Applicant or Employee
__________________________
Date
____________________________________
Please print your name
__________________________
Driver’s license number
__________________________
Issued by which state
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Your Letterhead
Sample Offer of Position Letter
SEND THIS LETTER CERTIFIED WITH RECIEPT
(Date)
Name of Near Future Employee
Address
City, State, Zip
Dear (Name):
We are pleased to offer you the position of
(job title) with
(Practice name) at a salary of $
per (hour / week / month). Your
primary responsibilities will be
. A copy of the job description is enclosed.
We are looking forward to seeing you on
(day of the week, month, and day)
at
a.m. At that time, we will introduce you to the team, show you around the office, and acquaint
you with our practice. We will also ask you to take a few minutes to complete several forms for benefits purposes
and to fulfill legal reporting requirements. Please bring identification with you appropriate for completing the
Immigration Employment Eligibility Verification form. During the orientation we will provide you with
information about our benefits and practice policies, as well as a copy of our Employee Handbook.
Employment with the practice is not for a specific term and can be terminated by you or by the practice at any time
for any reason, with or without cause. Any contrary representations which may have been made, or which may be
made to you, are superseded by this offer. Any additions to, or modifications of, this term of your employment
would have to be done in writing and signed by yourself and the owner of the practice. If you accept this offer, the
terms described in this letter shall become the terms of your employment.
We look forward to having you as a member of our team and we look forward to your acceptance of this offer. If
you accept the above described offer, please sign a copy of this letter and return it to me. This offer, if not accepted,
will expire on
(day of the week, month, day and year).
If you have any questions, feel free to call me at
(phone number).
Sincerely,
Name
I accept employment on the terms set forth above.
Signed
©2009 Roz Fulmer, Making a Difference…Today!
Date
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Your Letterhead
SAMPLE WORKING INTERVIEW LETTER
(Date)
(Name of Applicant)
(Address)
Dear (Name):
Are you as excited as we are? As part of the interviewing process for potential new employees,
our Practice requests that you schedule time for a “working interview.” During the working
interview we will be assessing your skill level, knowledge of the requirements of the position,
ability to follow direction, and attitude toward other team members and patients.
Wouldn’t you agree that it is as important to you as to ourselves to know that this is the job for
you? We request that you utilize the time to assess our Practice’s procedures, the way our team
members assist and support each other and most importantly, how we ensure that our patients
receive the best care possible. This is designed to be a useful time for both of us.
We would like you to arrive at the Practice at ____________ a.m./p.m. and work for _______
hours. We will pay you $_______ per hour. If you are not hired, your check will be mailed to
you at the address you provide within 72 hours. If you are hired, we will add these hours at the
above rate to your first paycheck. Please note that the rate for the working interview may not be
the same as the rate you will be paid upon hire.
The nature of employment at our Practice is “at will.” This means that you work for the Practice
at our will and you may be terminated with or without cause and with or without notice. This is
true for you, too. You work for the Practice at your will and you may leave with or without
cause and with or without notice. Were aware that this doctrine is part of the laws of our state
(Name of State)?
We look forward to the working interview and appreciate your application to our Practice and
part of our team.
Sincerely,
(Provider’s Name)
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
SAMPLE of WAIVER OF BENEFITS
Per Diem Employees
PER DIEM employees are those who routinely work either a full-time or a part-time schedule
and who waive participation in all but legally mandated benefit programs. (Practice name) offers
this category in limited classifications and to limited numbers of employees. Individuals
participating in this program must sign waivers of their rights to participate in the benefit
programs applicable to regular employees. Service in this category cannot be credited in any
way toward any benefit program, even if the employee is later assigned to a benefit-eligible
category. A change to or from this category can be accomplished only with the written consent
of (name of Practice).
I have read the above and understand that I will receive legally mandated benefits such as
workers’ compensation insurance coverage and Social Security, but am not eligible for the other
benefits offered by the Practice. I hereby waive my rights to those other benefits as a condition
of employment with (name of Practice).
I also understand that any change in my status will be presented to me in writing by (name of
Doctor).
_________________________________________
Employee Signature
_____________________________
Date
_________________________________________
Please Print Your Name
_____________________________
Witness and Date
__________________________________________
Doctor’s Name
______________________________
Date
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Here is a Sample of Non-Offer of Position after Interviewing
SEND THIS LETTER CERTIFIED WITH RECIEPT
SAMPLE NON-OFFER OF POSITION AFTER INTERVIEWING
Date
Name of Interviewer
Address
Dear
:
As you witnessed Monday evening during our interview process many exceptionally qualified
candidates like yourself interviewed for the assistant and appointment scheduler position. While
your application was among one of the best, we regret to inform you that we cannot at this time
extend to you the job offer. With your excellent wealth of experience, we are certain that you
will find a suitable position very soon. We wish you much success in your job search and we
thank you for your interest in our practice.
It was a pleasure meeting you.
Sincerely,
Name of Provider
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
SAMPLE WAGE GARISHMENT LETTER
SEND THIS LETTER CERTIFIED WITH RECIEPT
Date:
To:
Employee Name
From:
Doctor’s Name or Name of Practice / Payroll
Re:
Wage Garnishment
Did you know that (Practice name) has received a wage garnishment order from
, which requires that funds be withheld from your regular paychecks to pay off all
amounts due.
According to the garnishment order, $
is currently due. Under our state law
(Name of State), (Provider’s Name) is allowed to withhold an additional $5.00 per paycheck to
help cover administrative costs related to enforcement of the garnishment.
To that end, each pay period $
will be withheld from your paycheck, with
$
of that amount being sent to
on your
behalf. The withholding from your check will begin with the paycheck to be issued on (date of
first paycheck reflecting withholding), and will continue until your balance due is paid in full
(for amounts due in arrears).
You will be given copies of all checks, notices and correspondence sent by (Provider’s Name) to
regarding this garnishment.
If you have any questions, please see
.
Sincerely yours,
Provider’s Name
©2009 Roz Fulmer, Making a Difference…Today!
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Your Letterhead
Here is a Sample of COBRA NOTICE for Employees that are offered Health Insurance
(Insert Today’s Date)
Potential Employee’s Name
Address
City, State, Zip
SAMPLE:
Joe Employee and Spouse and Eligible Dependents
1000 Hamilton Road
San Jose, CA 95130
RE:
Continuation of Coverage
Dear Joe and Spouse and Eligible Dependents:
Due to your termination of employment on October 10, 2006, your group medical and/or dental benefits
(and the benefits of your covered eligible dependents) will expire on October 31, 2006.
Under the Consolidated Omnibus Reconciliation Act (herein called COBRA), if your group health
benefits end due to a “qualifying event” you may elect to continue your coverage under your current plan
provided you are not entitled to Medicare.
Continuation of coverage is available due to the following qualifying events:
1. termination of employment (other than for gross misconduct) or loss of coverage due to a
reduction of hours worked,
2. death of the employee,
3. divorce or legal separation,
4. loss of coverage due to the employee becoming entitled to Medicare, or,
5. a dependent child ceasing to qualify as a dependent under the plan
If elected, the continued coverage will end on the earlier of the following:
1. (a)
18 months after the date of termination of employment (other than for gross misconduct)
or reduction of hours worked so as to render the employee ineligible for coverage
(however, if a second qualifying event occurs within this 18-month period, the period of
coverage for any affected dependent may be extended up to 36 months from the first day
of the first qualifying event); or *
©2009 Roz Fulmer, Making a Difference…Today!
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(b)
36 months after the date of any other qualifying event
2. the date the employer ceases to provide any group health plan to any employee;
3. the date the employee or eligible dependent fails to make any required premium payment when
due;
4. the first day after the date of election the employee or eligible dependent becomes covered under
any other group health plan unless the other group health plan
5. the date the employee or eligible dependent is entitled to Medicare.
* It should be noted that either the 18 or 36 month periods commence from the first day of the qualifying
event, regardless of the date coverage is lost under the active plan.
An additional 11 months extension may be added to your original 18 months if you: (1) satisfy the legal
requirements for being totally and permanently disabled under the Social Security Act at the time of the
original qualifying event, (2) have been certified as being so disabled on this date by the Social Security
Administration (SSA) during your original 18 month extension, and (3) request this 11 month extension
within 60 days from receiving notice from the SSA. Proof of eligibility must be provided to qualify for
this extension. Also, the premium charge for the additional 11 month period will be 150% of the
premium rates outlined below.
In order to continue coverage, election must be made within 60 days after the date of this notice
(December 1, 2006), or 60 days after your qualifying event (December 10, 2006), whichever is later.
Election may be made by completing and returning the enclosed COBRA Enrollment Form and Health
Continuation Election Form to Generous Company, Inc. If there is any coverage elected on a retroactive
basis, the payment for the retroactive period plus premiums to current must be made within 45 days of the
election. All other premiums are payable on a monthly basis and given a 30 day grace period. If
payments are not received within the grace period, coverage will terminate. If any statements for
premiums are received after coverage expires for any reason, they should be disregarded. Continued
billing is not to be considered an extension of coverage. If your COBRA coverage expires due to the
expiration of the maximum period, you may be eligible for a conversion policy which may contain
different coverage provisions and rates.
You are currently enrolled in family medical (ABC Insurance PPO) and employee only dental (ABC
Insurance Dental HMO) coverage. You may only continue coverage which is already in effect; you may
not add coverage for dependents not already covered on the date of your qualifying event. You may only
elect dental coverage if you also elect medical coverage, or can provide proof of other medical coverage
to ABC Insurance.
The monthly premium charged for continued coverage, if elected, under the plan is as follows: (Contact
your Health Care insurance for correct rates:
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
SAMPLE:
Employee Only
Two Party
(Employee +1
dependent)
Family
MEDICAL:
HMO Option
$104.82
MEDICAL:
PPO Option
$150.69
MEDICAL:
Out of State
$159.38
$230.58
$331.53
$350.65
$335.38
$482.23
$510.02
Please note: the above rates include a 2% administration charge as allowed by COBRA, for Generous
Company, Inc. to administer the requested coverage. In the case of the additional 11 month extension
quoted above (with a 150% rate charge) Generous Company, Inc. will charge 148% of the rates above,
since the 2% fee is already included.
Payments are due on the first of each month for the following month. A 30-day grace period will apply;
after this period your coverage will be terminated if payment is not received. Checks or money orders
should be made payable to Generous Company, Inc. and sent to the address listed below:.
Generous Company, Inc.
Attn: Human Resource Department
6600 Main Street
Pleasantville, CA 94025
If you choose to continue your medical and/or dental coverage benefits, you will receive the same level of
benefits that Generous Company, Inc. provides for active employees. If Generous Company, Inc. amends
our policy during the Period of Health Benefit Continuation to either increase or decrease benefits, this
may result in the subsequent increase or decrease of premiums you will pay. Subject to your payment of
the required premiums, the medical and/or dental coverage benefits which are being continued for your
and your eligible dependents, if any, will be automatically increased or decreased as of the effective date
of such policy amendment. You will be notified in writing of any such changes.
Be sure to return the following forms to the Plan Administrator (Human Resource Department, Generous
Company, Inc.):



Acknowledgment of Receipt of Notification of COBRA Rights
COBRA Enrollment Form
Health Continuation Election Form
A return mailing envelope is provided for your convenience in submitting the forms.
If you have any questions, please contact the Human Resource Department at (999) 455-1111 during
regular business hours.
Sincerely,
Provider’s Name
©2009 Roz Fulmer, Making a Difference…Today!
95
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Your Letterhead
MASTER PREGNANCY / MEDICAL LEAVE CHECKLIST
Employee's Name
Date

Employee’s Medical Doctor’s certification of medical necessity for leave

Employee’s Medical Doctor’s verification of projected date of return

Notification given to employee of type of leave being taken, effective date, length of
available leave, status of accrued paid time which could be applied, coverage under
medical insurance, and verification of continued accruals (i.e., vacation).

Copy of State Disability Insurance pamphlet (must be given at the time of the leave even
though the employee may have received a copy previously) (can be found at the state’s
disability website)

If employee is receiving health care coverage from the practice then this must be given:
*Notice of COBRA Rights to Employee -- and if the employee rejects COBRA coverage,
confirmation that the employee's qualified beneficiaries received notification

*Acknowledgment of Receipt of Notification of COBRA Rights
*These should be sent at the time the employee is no longer eligible for company-provided
medical benefits.
You do have to provide all terminating employees with notice of special state programs under
the Health Insurance Premium Payment Program (HIPP) regardless of the number of employees.
©2009 Roz Fulmer, Making a Difference…Today!
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Pregnancy Disability Leave Notice
Under the Federal Fair Employment and Housing Act (FEHA), if you are disabled by pregnancy,
childbirth, or related medical conditions, you are eligible to take a pregnancy disability leave
(PDL). If you are affected by pregnancy or a related medical condition, you are also eligible to
transfer to a less strenuous or hazardous position or to less strenuous or hazardous duties, if this
transfer is medically advisable.
 The PDL (Pregnancy Disability Leave) for any period(s) or actual disability cause by your
pregnancy, childbirth, or related medical conditions up to four months (or 88 workdays for a
full time employee) per pregnancy.
 The PDL (Pregnancy Disability Leave) does not need to be taken in one continuous period of
time, but can be taken on an as-needed basis.
 Time off needed for prenatal care, severe morning sickness, doctor-ordered bed rest,
childbirth, and recovery from childbirth would all be covered by your PDL (Pregnancy
Disability Leave).
 Generally, we are required to treat your pregnancy disability the same as we treat other
disabilities of similarly situated employees. This affects whether your leave will be paid or
unpaid.
 Note: You may be required to obtain a certification from your health care provider of
your pregnancy disability or the medical advisability of a transfer. The certification
should include:
1.
the date on which you became disabled due to pregnancy or the date of the
medical advisability for the transfer;
2.
the probable duration of the period(s) of disability or the period(s) for the
advisability of the transfer; and
3.
a statement that, due to the disability, you are unable to work at all or to perform
any one or more of the essential functions of your position without undue risk to
yourself, the successful completion of your pregnancy, or to other persons or a
statement that, due to your pregnancy, the transfer is medically advisable.
 At your option, you can use any accrued vacation or other accrued time off as part of your
pregnancy disability leave before taking the remainder of your leave as an unpaid leave. We
may require that you use up any available sick leave during your leave. You may also be
eligible for state disability insurance for the unpaid portion of your leave.
 Taking a Pregnancy Disability Leave may impact certain of your benefits and your seniority
date.
©2009 Roz Fulmer, Making a Difference…Today!
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_____________________________________________________________________________
Your Letterhead
Here is a Sample of SAMPLE RETURN-TO-WORK FORM
Pregnancy Disability Leave LETTER
SEND THIS LETTER CERTIFIED WITH RECIEPT
(Date)
Name
Address
Dear
We hope you and your new baby are doing well and we send your family our best wishes.
The purpose of this letter is to advise you of your rights based on our state law of (name of State)
as it relates to maternity leave. As you may know, you are entitled to up to four months of
pregnancy disability leave for disabilities relating to pregnancy and childbirth.
According to our records, your last day of work was ________________ which means that your
four months of leave will be up as of __________________, is that correct? We are required to
hold your position open for you through the period of your pregnancy disability leave up to four
months and we are doing that per our agreement. Are you still in agreement that you will be
returning to your position by __________________? Please let me know if you will be able to
report to work at the end of your leave at least two weeks prior to that date.
We have appreciated your contributions to the practice and look forward to hearing from you.
We also can not wait to have you back as part of our team.
Sincerely,
Name of Provider
©2009 Roz Fulmer, Making a Difference…Today!
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Acknowledgements
When was the last time that you got to fulfill one of your dreams? These past few years, many
of you have helped me fulfill one of my dreams “Making a Difference...Today”!
To all my awesome and outstanding clients in the past, now and into the future, I thank you for
asking me to help you “Make a Difference…Today!” for yourselves and most importantly your
patients.
To Steve Anderson who without his help, support and confidence in and to me this book would
not be getting completed.
To Greg Sneyd for his friendship, guidance and support as well.
Greg Anderson and the entire network of the Crown Council, Thank You!
To my “Sisters” Susan, Pat, Linda, Brenda, Rhonda, Michelle, and all my other friends, thank
you for your love and support as well.
To a counselor, Gene who knew me better than I knew myself many years ago as he showed me
the way back and I will be forever grateful.
Finally, my husband Mike and daughters Marianne & Toni, without their understanding,
patience’s and love I would not be doing what I love to do; “Making a Difference…Today!” for
them and you, my clients. Christopher, Arianna and Andrew, Nana loves you even when I am
away.
If I have forgotten anyone, please accept my apologies as everyone who I have known and know
today has “Made a Difference” in my life and I am forever grateful.
Roz’s Contact Information:
E-mail:roz@rozfulmer.com
Website: www.rozfulmer.com
Office phone: Cell Phone: 815-481-3851
2738 Becker Drive
Peru IL 61354
Fax: 267-220-1691
©2009 Roz Fulmer, Making a Difference…Today!
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Roz Fulmer, Practice EXCELerator
“Making a Difference…Today!”
Roz Fulmer, Founder and CEO of “Making a Difference…Today” has owned several private
businesses and managed a dental practice for a combination of over 25 years of business
experience. She knows how to run a practice like a business and how to give excellent Five- star
plus customer service to both patients and to dental practices. Roz is renowned for her “verbal”
skills, case acceptance and getting patients to PAY…..TODAY! Roz has worked in partnership
with Pat Worcester, RDH training dental hygienists, hygiene assistants and administrators in
skills of proper scheduling, insurance filing, financial arrangements, case presentations, and
overcoming challenges of a dental practice.
As a practice advisor, Roz customizes each practice proposal and visits to fit the needs and
wants to the dentist and for his/her team members. She also was a past presenter of Financial
Seminars for Dental Boot Kamp and as well as one of their “implementation coaches” and
presenters for 8 plus years. Her vision as a practice advisor is to teach others so that they may
learn how to be better service givers to patients, to give support, compassion and harmony to
team members, and to know that a TEAM means Together Everyone Achieves More: No one
walks or does it alone.
Her greatest joy in life is her family, golfing and traveling with husband Michael, their daughters
Toni Marie and Marianne plus her grandchildren, Christopher, Arianna and Andrew.
©2009 Roz Fulmer, Making a Difference…Today!
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