8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
ORAL AND MAXILLOFACIAL SURGERY
I hereby request surgical privileges in the specialty of Oral and Maxillofacial
Surgery as shown in this form. I understand that privileges granted are subject
to a bi-annual review coinciding with reapplication for medical staff membership.
I also understand that application for additional or new procedures can be made at
any time with proper documentation.
lease indicate with an !"# in the appropriate box and by signature at the end of
this document the procedures you are requesting privileges for.
$pplied for $pproved
%&'(O$)*&O)$+ S,+-&+.
Includes/ but is not limited to/ surgery involving the
teeth and their supporting structures
.&S 'O
M$"I))O0$1I$) S,+-&+.
Includes but is not limited to/ surgical management of
injuries to the maxillofacial structures
.&S 'O
-&'&+$) +&1O'S(+,1(I*& S,+-&+.
Includes/ but is not limited to/ the reconstruction of
maxillofacial
.&S 'O
+&-+OS(2&(I1 +&1O'S(+,1(I*& S,+-&+.
Includes/ but is not limited to/ surgical preparation of
the mouth for wearing prosthesis3 placement of implants
.&S 'O
S,+-I1$) (+&$(M&'( O0 $(2O)O-. O0 M$"I))O0$1I$)
S(+,1(,+&S
Includes/ but is not limited to/ surgical management of
cysts/ simple neoplasms/ salivary gland diseases
.&S 'O
O+(2O-'$(2I1 +&1O'S(+,1(I*&
Includes but is not limited to osteotomies for correction
of growth discrepancies of the jaws and their contiguous
structures
.&S 'O
(&MO+$M$'%I4,)$+ 5OI'( S,+-&+.
Includes/ but not limited to surgical management of
dysfunctions of the (M5
.&S 'O
.&S 'O
Radiography Use of Modaliy ! i"erpreaio" of i#ages
$herape%i& a"d diag"osi&'
.&S 'O
Ulraso%"d Use of Modaliy ! i"erpreaio" of i#ages
$herape%i& a"d diag"osi&'
.&S 'O
Fl%oros&opy Use of Modaliy (ih Sae Li&e"se !
i"erpreaio" of i#ages $herape%i& a"d diag"osi&6
.&S 'O
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Lo&al a"eshesia .&S 'O
Co"s&io%s Sedaio" .&S 'O
S%per)isio" of Co"s&io%s Sedaio" *rai"ed Regisered
N%rse
.&S 'O
O(2&+S 'O( )IS(&%
.&S 'O
.&S 'O
.&S 'O

Signature of $pplicant %ate

Signature of 7I committee chairperson %ate recommended

Signature of -overning 4ody chairperson %ate recommended