Radiation Health & Safety Patient Forms

Radiographic Procedure Patient Consent

Patient’s First Name

Patient’s Last Name

Student’s First Name

Student’s Last Name

I, the Patient (Patient’s Name added above), give authorization to have my x-rays of my body taken by the Student (as the Student’s Name added above), a dental assisting student of Fullerton Dental Assistant School, to satisfy his/her radiation health and safety certification requirements.

The full-mouth x-ray series will present periapical and bitewing radiographic exposures (“the x-rays”). I understand that a dental assistant student does not diagnose illness, disease, or any other physical or mental disorder. As such, the dental assistant student prescribes neither medical treatment nor pharmaceuticals. It has been made very clear to me that the x-rays that will be provided to me should be brought to a dentist to complete a dental examination and diagnosis. These x-rays are not being taken to treat or diagnose any current or pre-existing ailment or injury. Because certain dental procedures should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions.

I also understand that the dental assisting student identified above is a student in training and is not a licensed or registered dental assistant, dentist, doctor or nurse. I recognize that Fullerton Dental Assistant School supports this radiographic procedure in order to provide dental assisting students with practical hands-on experience and that I am receiving this radiographic procedure at no charge in light of these facts. No oral statements contrary to this disclosure have been stated to me.

Release such student and Fullerton Dental Assistant School, its affiliates, servants, agents or employees from any claims, demands, damages, actions or causes of action arising out of or in consequence of any loss, injury or damage to my person or property incurred in connection with the x-rays, notwithstanding that any such loss, injury or damage may have arisen by reason of the negligence of Fullerton Dental Assistant School, its affiliates, students, servants, agents or employees;
Fully understand that my participation in the radiographic procedure program is entirely voluntary and at my own risk;
Agree that Fullerton Dental Assistant School shall not be liable to me for: (a) any loss (including loss by theft) or damage to my property, or the property of others, which property shall be my sole risk; or (b) any injury to, or death of, any persons including me, in each case resulting from or in connection with the radiographic procedure or the Fullerton Dental Assistant School, or any of its employees, students or agents acts or omissions.
Agree to indemnify Fullerton Dental Assistant School, its affiliates, servants, agents or employees from any claims or demands which might be made against the Fullerton Dental Assistant School arising out of or in consequence of the radiographic procedure;
Represent that I am the full age of eighteen (18) years or older

Patient Medical Health History

Patient First Name

Patient Last Name

Patient’s Date of Birth

Physician’s Name

Physician’s Address

Briefly describe your general health

Checkbox Field

Measles

Jaundice

Epilepsy

Venereal disease

Diabetes

Rheumatic fever

Tuberculosis

Chicken Pox

Heart Attack

Hepatitis

Mumps

Stroke

Ulcers

Asthma

Thyroid Disease

Anemia

Liver Disease

Emotional disease

None

Have you been examined by a physician in the last year?

Yes

Have you ever had a serious illness?

Yes

Has there been any change in your health in the last year?

Yes

Have you ever had surgery? (An operation)

Yes

Have you gained or lost much weight recently?

Yes

Have you ever been treated for ear or eye trouble, other than corrective glasses?

Yes

Do you bleed for a long time when you cut yourself?

Yes

Have you ever had hives or a skin rash?

Yes

Have you ever been told you have heart trouble?

Yes

Do you get out of breath easily?

Yes

Do you have spells of dizziness?

Yes

Do your ankles ever become badly swollen?

Yes

Do you have high blood pressure?

Yes

Have you ever been told that you have a heart murmur?

Yes

Do you have any blood disorder?

Yes

Do you have asthma, hay fever, sinusitis or frequent sore throat?

Yes

Have you ever had tuberculosis, emphysema or other lung disease?

Yes

Do you have stomach trouble, frequent diarrhea or constipation?

Yes

Have you ever been told you have kidney or bladder trouble?

Yes

Have you ever had syphilis or gonorrhea?

Yes

Do you ever have fits, convulsions or seizures?

Yes

Do you have arthritis or joint trouble?

Yes

Are your joints often painfully swollen?

Yes

Have you had a general or local anesthetic?

Yes

Have you often had toothaches?

Yes

Do your gums bleed when you brush your teeth?

Yes

Do your gums itch when you brush your teeth?

Yes

Does it hurt when you chew?

Yes

Do you have any problems with your jaws?

Yes

Do you clench or grind your teeth?

Yes

Have you ever had an injury to your face, neck or jaw?

Yes

Do you suffer from frequent or severe headaches, neck or back pain?

Yes

Have you ever received x-ray or radiation therapy to the head or neck?

Yes

Do you have ear pain or pain in front of the ears?

Yes

Does your jaw feel tired after a big meal?

Yes

Must you chew on one side exclusively?

Yes

Is your sleep disturbed by pain of the head and neck region?

Yes

Are your daily activities or routine disturbed by pain of the head and neck region?

Yes

Do you consider yourself a nervous person?

Yes

Do you fee unhappy or depressed?

Yes

Are you easily upset?

Yes

Are you sensitive or allergic to any medicine

Yes

Are you sensitive or allergic to any of the following?

Penicillin

Novocain

Aspirin

Iodine

Codeine

Sleeping pills

Other

No Allergies

Please specify

Do you smoke or use tobacco?

Yes

Do you drink alcohol daily?

Yes

Are you pregnant?

Yes

Please specify

Are you in or have passed through menopause (change of life)?

Yes

Have you ever taken full mouth X-rays?

Yes

When did you last have radiographs (Full Mouth X-rays – 18-20 images) taken?

List all Prescription and Non-Prescription drugs taken or used in the past 3 months:

List all hospitalizations for any reason:

Patient’s Name

Patient’s Last Name