Forms Library

Dental Finance Forms

1. Assistant Salary Form

2. CPDA Form for courses from 1st April 2018 onwards

3. DA1 Form - Declaration for Health Service Committed Dentists (Please click here for guidance in relation to completion of DA1 form)

4. HS50 Form - Arrangement for Transfer of Patients

5. Maternity/Paternity/Adoption Payments Claim Form

6. OP2 Form - Claim for Long-Term Sickness Payments

7. OP4 Form - Return to Work Form

8. PREM1 Form - Reimbursement of Non-Domestic Rates

9. SEN 1 Form - Application for Seniority Payments


HS48 Forms 

Please click here to view forms and associated documentation for new entrants to the NI Dental List.


Dental Treatment Forms

1. DB100 Form - Stationery Order Form

2. DB114(a) Form - Orthodontic Diagnosis: Non-Appliance Cases

3. DIS1 Form - Paid Claim Adjustments

4. HS45DOC Form - Dental Care Orthodontic Acceptance

5. NON2 Form - Non Payment Enquiries  

6. RA1 Form - Application for Replacement of a Dental Appliance

7. WCA966 Form - Notice of Withdrawal from a Capitation or Continuing Care Arrangement



Dental Prescription Pads / Controlled Drugs

1. Letter regarding use of Dental Prescription Pads by second parties

2. Form authorising use of Dental Prescription Pad by a second party

3. DLRS Prescription Re-Ordering Forms

4. Link to Guidelines on Private Controlled Drugs

5. Controlled Drugs Self Assessment Questionnaire Declaration - Microsoft Word format

6. Controlled Drugs Self Assessment Questionnaire Declaration - PDF format