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About
Founders
Instructors
FAQs
Reviews
Courses
Dental Assistant
CPR and BLS
Coronal Polish
Infection Control & DPA
Pit & Fissure Sealant
Dental Assistant Radiology
RDA Written Review
Jobs
Find a Job
Post a Job
Resources
Class Videos
Course Forms
Contact
Call Us: 714-882-5518
Coronal Polish
Clinical Patient Check-Off List:
Clinical Patient Check-Off List
Please add the student name in the form below exactly as it appears on your ID
Student First Name
Student Last Name
Instructor Name
Completion date
Patient Name
Polish date
Student Initials
Date
Terms
The patient is at least 18 years of age.
The patient signed the release form.
The patient is rendered calculus free (Calculus Free Form is signed by a Dentist or Hygienist).
The patient’s health history form was completed and reviewed prior to beginning the procedure.
Plaque was shown to be present after initially disclosing the oral cavity.
The procedure was completed within a 45 minute time period.
Coronal polish “Evaluation Sheet” completed.
Add another patient
Yes
No
Patient Name
Polish date
Student Initials
Date
Terms
The patient is at least 18 years of age.
The patient signed the release form.
The patient is rendered calculus free (Calculus Free Form is signed by a Dentist or Hygienist).
The patient’s health history form was completed and reviewed prior to beginning the procedure.
Plaque was shown to be present after initially disclosing the oral cavity.
The procedure was completed within a 45 minute time period.
Coronal polish “Evaluation Sheet” completed.
Add another patient
Yes
No
Patient Name
Polish date
Student Initials
Date
Terms
The patient is at least 18 years of age.
The patient signed the release form.
The patient is rendered calculus free (Calculus Free Form is signed by a Dentist or Hygienist).
The patient’s health history form was completed and reviewed prior to beginning the procedure.
Plaque was shown to be present after initially disclosing the oral cavity.
The procedure was completed within a 45 minute time period.
Coronal polish “Evaluation Sheet” completed.
Submit Form
