I hereby give my permission for coronal polishing to be performed on me as part of clinical requirements for coronal polishing licensure.
I understand that no charge will be made for the service performed. In consideration thereof, I hereby agree to waive, release, hold harmless, defend and indemnify, as against any and all claims I or heirs may have nor or in the future against its principals and/or agents, arising out of or resulting from my voluntary participation as a patient in this coronal polish course.
I have read and I understand the terms of this agreement.