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Fillable Form Dentist Note

A dentist note is considered an official notification that the patient has visited a certain dentist and is suffering or has suffered from a problem.

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What is a Dentist Note?

A Dentist Note is a document that is typically provided by a dentist to a patient, or their employer, school, or insurance company, in order to verify a dental treatment or condition. This note may contain information about the diagnosis, treatment, and prognosis of a dental issue, as well as any recommendations for future care.

How do I fill out a Dentist Note?

Get a copy of Dentist Note template in PDF format.

Dentist’s Notes largely only require information about the patient and their condition as assessed by the dentist. However, depending on the nature of the patient’s condition, it may be useful to have additional documents attached to the note in order to prove the veracity of the note and to more accurately convey the patient’s current status.

Clinic Name

Enter the name of the dentist’s clinic.

Clinic Address

Enter the address information of the dentist’s clinic (street address, city, county, state, ZIP code)

Clinic Contact Number or Email

Enter the clinic’s contact number and/or primary email address.

Name of Patient

Enter the patient’s full legal name.

Date of Appointment or Examination

Enter the date that the patient last went to the dentist.

Procedure Done

Enter a short description of the procedure that the patient underwent.

Purpose of Note

Enter a short description of what this note is being used for (such as to excuse the patient from having to participate in something or exempting.

Return Date

Enter the date by which the patient is expected to recover enough to be able to return to work or school.

Dentist’s Comment

Enter any particular instructions, remarks, or otherwise made by the dentist in the space provided, as well as a description of the procedure/issue(s) that the patient is or was facing.


Enter the date that this note was created.

Doctor’s Name

Enter the name of the dentist.


Have the dentist sign the form in the space provided.

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Frequently Asked Questions (FAQs)

Are Dentist Notes part of my medical history?

Yes. Dentists are still healthcare providers, and as such it is important to record any treatment they administer to a patient for future purposes such as future dentist appointments or even possible future hospitalization.

Who has access to a patient's Dentist Note?

Access to a patient's Dentist Note is typically limited to the dental practice and healthcare providers who are directly involved in the patient's care, as well as other individuals or organizations authorized by the patient or required by law to access the information.

Who needs Dentist Notes?

Dentist Notes are provided by the patient (or someone they trust) to any other person or entity that requires them, such as their boss or the school they attend.

When do Dentist Notes need to be provided?

While there is no hard and fast deadline for Dentist Notes specifically, the deadline for documents like them that are meant to excuse a person from work or school or for any other reason will depend on the organization or person requesting that it be provided. It is safe to assume, however, that it is best to submit them to the relevant persons as soon as possible to avoid any issues.

Can I ask my dentist for a copy of a previous Dentist Note?

Yes and no. Dentists will keep records of what treatments and/or appointments a patient has had with them through the years, but they will rarely keep copies of specific notes on file. While it may not be possible for a dentist to provide an exact copy of a previous Dentist Note, they can still create a new note for the old information upon request.

How is the confidentiality of a patient's Dentist Note protected?

The confidentiality of a patient's Dentist Note is protected by a number of laws and regulations that govern the privacy and security of health information. Dentists and their staff are legally required to keep patient information confidential and ensure that it is only accessible by authorized individuals who need to know the information to provide care for the patient.

Can a patient's Dentist Note be accessed electronically?

Many practices nowadays provide ways to view and send Dentist Notes electronically. Make sure to check with your dentist to find out how to make use of that particular service.

Can a Dentist Note be shared with other dental professionals?

Yes, a Dentist Note can be shared with other dental professionals, but only with the patient's informed consent and in accordance with applicable laws and regulations. Sharing dental information with other dental professionals can be an important part of providing coordinated and effective care for the patient.

For example, if a patient is referred to a specialist for a specific dental procedure, their dentist may share relevant information from their dental record with the specialist to ensure that they have a complete understanding of the patient's dental history and treatment plan.

Can a Dentist Note be used for research purposes?

Yes, but only with the patient’s informed consent. In addition to this, the use of personal health information for research purposes is subject to a number of legal and ethical guidelines depending on the country. Make sure that you are practicing ethical research whenever using such information for the purposes of study.

What is informed consent?

Informed consent is when a patient understands why their information is being shared, who it will be shared with, and how it will be used. The patient has the right to refuse to share their information, except in cases where sharing the information is required by law, such as reporting certain communicable diseases to public health authorities.

Are Dentist Notes the same as Doctor’s or Nurse’s Notes?

No. While both are medical records about the patient’s health and any treatments they have gone through, Dentist Notes are specifically about a patient’s dental health and any issues relating to that, while Doctor and Nurse’s Notes are more general or focused on the Doctor’s field of expertise.

Can a patient request that information be added to or removed from their Dentist Note?

Yes. However, this request may or may not be granted depending on the circumstances surrounding the request. Under HIPAA regulations in the United States, patients have the right to request certain changes to their medical records, including their Dentist Notes, if they believe that the information contained in the record is inaccurate or incomplete. However, dental practices are not required to grant every request for changes to the patient's records. For example, if the Dentist Notes in question are accurate and complete, the practice may decline to make any changes. Additionally, there may be legal or regulatory reasons why certain information cannot be removed from the patient's records.

Can a Dentist Note be used as a basis for disciplinary action against a dentist?

Dental regulatory bodies, such as state dental boards, are responsible for enforcing standards of professional conduct and holding dentists accountable for any violations. If a patient's Dentist Note documents behavior or actions that violate these standards, such as providing substandard care, failing to obtain informed consent, or engaging in unprofessional conduct, the regulatory body may investigate and, if necessary, take disciplinary action against the dentist.

Can a patient's Dentist Note be used as evidence in a legal case?

If it is considered or believed to provide important information pertinent to the case, yes. Otherwise, it may not be accepted as evidence.

How often should a dentist update a patient's note?

In general, it is recommended that a patient's Dentist Note be updated at each dental visit, as this allows the dentist to document any changes in the patient's oral health status, the results of any diagnostic tests or procedures, and any treatments or interventions that were performed. This helps ensure that the patient's record remains accurate and up-to-date, and that any future healthcare providers have access to the most complete and accurate information possible. Depending on the patient’s circumstances, however, it may be beneficial to update the record more or less frequently.

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