Penn Dental Medicine Clinic Observation Visitor Submission
Please fill out the information below to begin the process of approval for clinic observations. Submissions must be submitted two (2) weeks prior to clinic observation start date. Failure to submit all required documentation may delay in the clinic observation start date approval.
Prospective Visitor First Name
Prospective Visitor Last Name
Prospective Telephone Number
Prospective Visitor Email
Please make sure your email is correct. Communication is through email only. If your email address is typed incorrectly, you will not receive notification.
Which program would you like to participate in?
Summer Program Participants
Post-Graduate Externship Program
International Student Program
Clinical Externship Program
Preventive & Restorative
Oral & Maxillofacial Surgery
Start Date of Clinic Observation
Please select the date of your 1st day of your Clinic Observation.
End Date of Clinic Observation
Please select the date of your last day of your Clinic Observation.
*Waiver for Visitor Observing in Clinical Areas Form
*Approval Flow Form
*Visitor Agreement to Appropriately Use Confidential Information Form
* Immunization Record
- Must have a current Flu shot dated: October 1st - April 1st. Must be completed annually.
- Must show results and dates of immunizations.
- PPD/ Tuberculosis must be current for a year.
Please attach your visitor application packet
Questions/ Concerns/ Follow Up
Please send an email:
Send me a copy of my responses
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