I, hereby declare that to the best of my knowledge and belief, I do not have or have not had in the past any systemic condition that can affect the pit and fissure sealant procedure. The disclosures of any of these conditions have been included in my medical health history. These systemic conditions include but are not limited to:
heart and/or kidney disease, herpes simplex, hepatitis, diabetes, epilepsy, positive HIV, AIDS, organic heart murmur and heart valve replacement. Disclosures of these conditions have been forthcoming on my signed and dated medical health history.
I also acknowledge that Fullerton Dental Assistant School or any participant in the pit and fissure sealant certification course will maintain and keep all course related documents confidential.