Name



Name:Click here to enter text.DEPARTMENT OF SURGERYSECTION OF DENTISTRY/ORAL SURGERYREQUEST FOR SPECIFIC PRIVILEGESGROUP 21.00Maxillofacial and Oral Surgery1.01?All Oral and Maxillofacial Surgery, Including Excision of Lesions1.02?Fractures Reduction, with Fixation1.03?Hydroxylapatite Synthetic Bone Graft Augmentation1.04?Mandibular Staple Operation1.05?Implants1.06?Orthognatic Surgery1.07?Osseointegrated Implant?Other Procedures (List):__________________________________________________________________ 2.00Pedodontics2.01?Orthodontic Tooth Movement2.02?Precious Metal Cast Restorations2.03?Apicoectomies2.04?Periodontal Surgery - Gingivectomy and Periodontal Flap2.05?Frenectomy2.06?Extraction of Impacted Primary and Permanent Teeth2.07?Extraction of Supernumerary Teeth2.08?Surgical Tooth Exposures2.09?Removal Prosthetic Treatment2.10?X-Rays, Including Full-Mouth Series, Cephalograms, and Panoramic X-Rays2.11?Pulp Testing2.12?Impressions2.13?Adult Prophys (Scaling and Curettage)2.14?Child Prophys2.15?Topical Fluoride Application2.16?Interceptive Orthodontics - Space Maintenance2.17?Amalgam and Composite Restorations on Primary and Permanent Teeth, Including Pin Restorations, and Restorations That Require Indirect Pulp Caps or Direct Pulp Caps2.18?Polycarbonate Crowns2.19?Stainless Steel Crowns2.20?Pulpotomy2.21?Endodontic Treatment - Root Canal Therapy on all Primary and Permanent Teeth, Including Host and Core Restorations 2.22?Extractions of Nonimpacted Primary and Permanent Teeth2.23?Therapy Primary/Perm. Teeth, Including Post & CoreRestorations2.24?Sealants2.25?Bonding2.26?Cosmetic Dentistry2.27?Non-Surgical Periodontal Therapy3.00General 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.4.00Periodontics4.01?Periodontal Surgery4.02?Dental Implant Placement4.03?Conservative, Non-surgical Periodontal Therapy5.00Prosthodontics5.01?Crowns5.02?Bridges5.03?Partial Dentures5.04?Complete Dentures SignatureDateClick here to enter a date.******************************************************************************Department:Reviewed and recommended, as requested:_____Reviewed and recommended, with exception:_____Reviewed but not recommended:___________________________________________________________________________________ChairpersonDateMedical 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. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download