Request for specific privileges

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1.00 Maxillofacial and Oral Surgery

1.01 ☐ All Oral and Maxillofacial Surgery, Including

Excision of Lesions

1.02 ☐ Fractures Reduction, with Fixation

1.03 ☐ Hydroxylapatite Synthetic Bone Graft Augmentation

1.04 ☐ Mandibular Staple Operation

1.05 ☐ Implants

1.06 ☐ Orthognatic Surgery

1.07 ☐ Osseointegrated Implant

☐ Other Procedures (List):_______________________


2.00 Pedodontics

2.01 ☐ Orthodontic Tooth Movement

2.02 ☐ Precious Metal Cast Restorations

2.03 ☐ Apicoectomies

2.04 ☐ Periodontal Surgery - Gingivectomy and Periodontal Flap

2.05 ☐ Frenectomy

2.06 ☐ Extraction of Impacted Primary and Permanent Teeth

2.07 ☐ Extraction of Supernumerary Teeth

2.08 ☐ Surgical Tooth Exposures

2.09 ☐ Removal Prosthetic Treatment

2.10 ☐ X-Rays, Including Full-Mouth Series, Cephalograms, and Panoramic X-Rays

2.11 ☐ Pulp Testing

2.12 ☐ Impressions

2.13 ☐ Adult Prophys (Scaling and Curettage)

2.14 ☐ Child Prophys

2.15 ☐ Topical Fluoride Application

2.16 ☐ Interceptive Orthodontics - Space Maintenance

2.17 ☐ Amalgam and Composite Restorations on Primary and

Permanent Teeth, Including Pin Restorations, and Restorations That Require Indirect Pulp Caps or Direct Pulp Caps

2.18 ☐ Polycarbonate Crowns

2.19 ☐ Stainless Steel Crowns

2.20 ☐ Pulpotomy

2.21 ☐ Endodontic Treatment - Root Canal Therapy on all Primary and Permanent Teeth, Including Host and Core Restorations

2.22 ☐ Extractions of Nonimpacted Primary and Permanent Teeth

2.23 ☐ Therapy Primary/Perm. Teeth, Including Post & Core


2.24 ☐ Sealants

2.25 ☐ Bonding

2.26 ☐ Cosmetic Dentistry

2.27 ☐ Non-Surgical Periodontal Therapy

3.00 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.

4.00 Periodontics

4.01 ☐ Periodontal Surgery

4.02 ☐ Dental Implant Placement

4.03 ☐ Conservative, Non-surgical Periodontal Therapy

5.00 Prosthodontics

5.01 ☐ Crowns

5.02 ☐ Bridges

5.03 ☐ Partial Dentures

5.04 ☐ Complete Dentures



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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.

Directory: files -> physician-services -> medical-staff-office
files -> Southern California Regional Dentistry Post-Baccalaureate Program ucla & Loma Linda, Schools of Dentistry
files -> Pursuing a career in Dentistry What's Unique about Dentistry?
files -> The university of michigan school of dentistry honor system policy for students enrolled in advanced dental education programs
files -> Curriculum vitae laurie k. Mccauley
files -> To be eligible to apply for core privileges in dentistry, the applicant must meet the following qualifications
files -> North-Western State medical University n a. I. I. Mechnikov Program for General Medicine Department
files -> National medical university of LVIV department of therapeutic dentistry
files -> An Annotated List of Websites Related to Geriatric Education for Dentists and Dental Hygienists
medical-staff-office -> Request for specific privileges
medical-staff-office -> Female Pelvic Medicine/Reconstructive Surgery (Urogynecology) Clinical Privileges

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