Name: Click here to enter text.
DEPARTMENT OF SURGERY
SECTION OF DENTISTRY/ORAL SURGERY
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 2
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1.01
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1.06
1.07
2.00
2.01
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2.04
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Maxillofacial and Oral Surgery
☐
All Oral and Maxillofacial Surgery, Including
Excision of Lesions
☐
Fractures Reduction, with Fixation
☐
Hydroxylapatite Synthetic Bone Graft Augmentation
☐
Mandibular Staple Operation
☐
Implants
☐
Orthognatic Surgery
☐
Osseointegrated Implant
☐
Other Procedures (List):_______________________
___________________________________________
Pedodontics
☐
Orthodontic Tooth Movement
☐
Precious Metal Cast Restorations
☐
Apicoectomies
☐
Periodontal Surgery - Gingivectomy and Periodontal
Flap
☐
Frenectomy
☐
Extraction of Impacted Primary and Permanent Teeth
☐
Extraction of Supernumerary Teeth
☐
Surgical Tooth Exposures
☐
Removal Prosthetic Treatment
☐
X-Rays, Including Full-Mouth Series, Cephalograms,
and Panoramic X-Rays
☐
Pulp Testing
☐
Impressions
☐
Adult Prophys (Scaling and Curettage)
☐
Child Prophys
☐
Topical Fluoride Application
☐
Interceptive Orthodontics - Space Maintenance
☐
Amalgam and Composite Restorations on Primary and
Permanent Teeth, Including Pin Restorations, and
☐
Polycarbonate Crowns
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Stainless Steel Crowns
☐
Pulpotomy
☐
Endodontic Treatment - Root Canal Therapy on all
Primary and Permanent Teeth, Including Host and
Core Restorations
☐
Extractions of Nonimpacted Primary and Permanent
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Teeth
☐
Therapy Primary/Perm. Teeth, Including Post & Core
Restorations
☐
Sealants
☐
Bonding
☐
Cosmetic Dentistry
☐
Non-Surgical Periodontal Therapy
General Dentistry
☐
General dentists are requested to list the procedures
you wish to perform, based on evidence submitted of
past training or experience. Operating room
privileges may be granted on an individual basis for
certain procedures.
Periodontics
☐
Periodontal Surgery
☐
Dental Implant Placement
☐
Conservative, Non-surgical Periodontal Therapy
Prosthodontics
☐
Crowns
☐
Bridges
☐
Partial Dentures
☐
Complete Dentures
Signature
Date Click here to enter a date.
******************************************************************************
Department:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
______________________________________________________________________________
Chairperson
Date
Medical Staff Executive Committee:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
Date____________________
Board of Hospital Managers:
Reviewed and approved, as recommended:_____
Reviewed and approved, with exception:_____
Reviewed but not approved:_____
Date____________________
Note: If privileges are denied, limited, or granted other than as requested,
documentation must be provided.
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