Dear Dental Health Care Provider, - University of Alaska Anchorage 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the student's name at the top of the form. This identifies who the permission is for.
3. In the section regarding dental decay, select 'Yes' or 'No' based on the patient's current condition. If 'Yes', provide details about the areas of decay and outline a treatment plan, including completion dates.
4. Fill in the date of the last prophylaxis if known. This information helps track the patient's dental health history.
5. Next, assess and document the patient’s periodontal status in the designated field.
6. Finally, print and sign your name as the provider, along with your telephone number and date to complete the form.

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