Hello everyone, welcome back to another summer here at the S.O.
D for those of you who may
not know me my name is Jose Rios and I am the GPL Administrative Assistant. I am here to help both the
GPLS and students with anything they might need. I just have a few quick announcements for everyone.
As many of you may already know Amanda Rico is no longer here at the school so please direct any
questions you might have to your GPL or myself.
Inactivations/Dismissals: We will be moving back to the inactivation forms we used before the
pandemic. They are located on the clinic floor between row A and B Chris Davis our dental assistant can
show you where if you cannot locate them. All inactivations, deletes, and dismissals must be approved
by your GPL before sending them to me. If you do not know the different between
delete/inactivate/dismiss, the bottom of the form has the information.
Patient Dismissal/Inactive Form
Circle one: Inactivate / Dismiss / Delete Date:
_______________
Patient Name: __________________________________ Patient MRN:
__________________________________
No Show Dates: _________________________________ Left Voicemail Dates:
___________________________
_______________________________________________
_____________________________________________
Reason for Dismissal/Inactivity:
_____________________________________________________________________________________
_____________
_____________________________________________________________________________________
_____________
GPL Name: _______________________________ GPL Signature:
______________________________
Student Name: _____________________________
Inactivate - Cannot reach patient, called at least 3 times over at least a 3-week period
Dismissed - 2 or more NPV no-shows OR 3 or more normal apt. no-shows, behavior issues.
Delete- Patient no longer wants to be seen here OR referred to another clinic due to complexity of care.
*Make sure you enter a documentation note in Epic before turning in this form
Patient Transfers: I know many of you have recently received a large number of patients transferred to
you by your upper classman. If you are transferring some of those patients, please remember that all
patient transfers must also be approved by your GPL before the change can be made. Make sure when
you are transferring a patient you fill out the correct form as well. Both of these forms are also located
on the clinic floor. One will refer a patient to your classmates for a specific procedure the other will
transfer the patient permanently.
Student-to-Student Patient Referral form
Date______________
Assigned Student______________________________
Temporary Student____________________________
Patient name_________________________________
MRN___________________________
TX Temporary Student will do:
__________________________________________________________________________________________
Assigned Student signature_______________________
Temporary student signature______________________
GPL Name_____________________________________
GPL Signature__________________________________
*Referral will only be honored for 1 to 2 appointments
Process:
1.Fill out Referral form completely
2. Have GPL approve the referral (with signature)
3. Turn in to front desk and have them schedule the appointments with referral student (this form must be filled out before you make appointments with referral
student
Patient Transfer form Date_______________________
Current Student___________________________________________
New Student_____________________________________________
Patient name_____________________________________________
MRN____________________________________________________
Reason for transfer request:
________________________________________________________________________________________________________________
Perio recall due date: ____________________________________
Exam due date: ___________________________________________
Does assigned student still have at least 6 recall patients? (check one): Yes No
Patient has been informed of transfer
Assigned Student Signature_________________________________
New Student Signature_____________________________________
GPL Name_______________________________________________
GPL Signature____________________________________________
D2’s cannot do the following procedures:
Dentures
Implants
Complex treatment
Fixed (until Spring of D2 year)
Process:1.Fill out form completely 2. Have GPL approve the transfer (with signature)3. Turn in form to GPL Administrative Assistant
Clinic Contacts
Here is a list of all of the contacts for the clinics where you will be doing your rotations. If you
are sick or cannot make it in for whatever reason to one of these clinics please inform the administrative
assistant, the contacts for that clinic, your GPL and Jennifer Tateoka.
This will allow for the staff of that clinic to:
Find coverage for you patients
Allow the admin staff to track your absences
Allow Jennifer to block off your schedule for the day.
Greenwood:
S.O.D:
Jennifer Tateoka (Templet Specialist): [email protected]
Melissa Leiataua (Front Desk Lead): [email protected]
South Main:
Tiffany Failner (Dental Assistant): [email protected]
Liberty:
[email protected]
Rose Park:
[email protected]
[email protected]
