Form - Pit & Fissure Sealant Patient Forms

PIt & fissure Sealant – Consolidated Patient Form – Medical History & Consent (#62)

Section 1 – Patient Information

Section 2 – Medical/Dental Health History

Section 3 – Consent & Release

I authorize dental assisting students under the supervision of a licensed dentist to perform: Pit & Fissure Sealants (on qualifying teeth)

I understand these are educational procedures provided at no cost and are not a substitute for treatment. I release the school, its students, and supervising faculty from liability related to these procedures.

Section 4 – Acknowledgement & Signatures

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Pit & Fissure Sealant Patient Forms

Patient Medical Health History

Directions: Read each question and individually mark YES or NO to the following:

Are you sensitive or allergic to any of the following?

Patient’s Profile