Coronal Polishing
Patient Consent & Health History

Coronal Polish Patient Forms

Coronal Polishing Patient Consent

Coronal Polishing Patient 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?

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Coronal Polish – Consolidated Patient Form – Medical History & Consent

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: Coronal Polishing (removal of plaque/stains, not a full cleaning)

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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