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  3. Adverse Occurrence Report

Adverse Occurrence Report

Form used to report any death or incident causing a patient temporary or permanent physical or mental injury occurring in a dental outpatient facility.

Document Type
Forms
Resource Link
https://azadoagov.na1.echosign.com/public/esignWidget?wid=CBFCIBAA3AAABLblqZhBT…
Adverse_Action_Report.pdf
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Arizona State Board of Dental Examiners

1740 W Adams Suite 2470

Phoenix, AZ 85007

Phone: (602) 242-1492
Fax: (602) 242-1445

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