Sample Written Work Order Allowing General Supervision in Dental Office

Unless and until altered or revoked by me in writing, at all times when I am not physically present in the office, I hereby authorize any dental hygienist employed by my office who holds a current certification in Basic or Advanced Cardiac Life Support by an association approved by the New Jersey State Board of Dentistry to perform, upon an existing patient of record only, any service a dental hygienist is allowed by law to perform. However, when a dentist is not physically present in the office, a dental hygienist cannot, under any circumstance, (1) administer local anesthesia, (2) monitor a patient to whom nitrous oxide has been administered or (3) perform any other anesthetic procedure except as may be designated by the State Board.

Signature_________________________________________________________

Date____________________

Lorraine Sedor

2016-10-10

Microsoft