This is information that will be gathered about possible PATIENT EXPOSURES. This information will only be sent to Jane and Dr. Rossi. 
Only the patient's chart number should be included in the form. 
Please fill in each section of this form and provide any additional info you feel is important. 
The Risk Manager will contact you with any additional questions if needed.

Are you an Employee (Faculty/Staff), Student or Resident of MUSOD?
Select the dental school clinic/area that the patient is/was seen or scheduled to be seen in on the day of notification (Minimum one)
  •
<div>Appointment date<br></div>
Month Day Year  
 
Did the patient come to the dental school building for the appointment?