Patient Medical History
Medical Health Statement
Patient release Form
Sealant Patient Criteria Form

Patient Medical History

PATIENT MEDICAL HISTORY

Please add your name in the form below exactly as it appears on your ID

Patient’s Name

Patient’s Last Name

Address: City: State: Zip:

Phone

Physician Name

Dentist Name

Age

Physician Phone

Dentist Phone

Date Of Birth

Physician Address

Dentist Address

Name Of Student

MEDICAL HEALTH STATEMENT

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.

PATIENT RELEASE FORM

I hereby give my permission for a pit and fissure sealant to be performed on me as part of a clinical requirement for pit and fissure sealant certification.
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 my heirs may have now or in the future against its principals and/or agents, arising out of or resulting from my voluntary participation as a patient in the dental trainee program.

Pit and Fissure Sealant Patient Criteria Form

Date / Time

Patient Name

The patient named above has been examined by the faculty member and meets the following criteria:
• Patient must be 18 years of age or older.
• Patient must be in good health. (A medical history form will be completed prior to
treatment and approved by the instructor.)
• Each patient will have a minimum of four (4) virgin, non-restored, natural teeth,
sufficiently erupted so that a dry field can be maintained. In addition, each patient will
have a minimum of one tooth in all four quadrants.
• Patients with another 4 qualifying teeth (1 tooth per quadrant) can serve as an additional patient.
• Third molars (#1, 16, 17, and 32) cannot be used to be sealed

Signature

Sign Here

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Patient Medical History
Medical Health Statement
Patient release Form
Sealant Patient Criteria Form