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COLLABORATIVE AGREEMENT SOUTH DAKOTA Agreement Between: Supervising Dentists Name: Work Address:Work Phone:Work Fax:Email:License #:Dental Hygienists Name: Work Address:Work Phone:Work Fax:Email:License
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How to fill out public health supervision agreement

01
Step 1: Obtain a copy of the public health supervision agreement form.
02
Step 2: Read the agreement form carefully and make sure you understand all the provisions and requirements.
03
Step 3: Fill out the personal information section, including your name, address, contact details, and any other requested information.
04
Step 4: Provide information about your medical history, including any known health conditions or previous illnesses.
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Step 5: If applicable, list any medications you are currently taking or any known allergies.
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Step 6: Review the terms of the agreement, including the duration of the health supervision period and any specific monitoring requirements.
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Step 7: Sign and date the agreement form.
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Step 8: Submit the filled-out form to the relevant public health authority or healthcare provider.

Who needs public health supervision agreement?

01
Public health supervision agreement may be required by individuals who have been diagnosed with a contagious disease or those who are at risk of spreading a communicable illness.
02
It is commonly needed by individuals with conditions such as tuberculosis, sexually transmitted infections, or other contagious diseases that require close monitoring to prevent the transmission of the disease to others.
03
Healthcare workers who have been exposed to a potentially infectious situation or have a high risk of disease transmission may also need to fill out a public health supervision agreement.
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