Coronal Polishing
Patient Consent & Health History

Coronal Polish Patient Forms

Patient’s First Name

Patient’s Last Name

Student’s First Name

Student’s Last Name

Coronal Polishing Patient Consent

* I give authorization to have my teeth coronal polished by , a dental assistant student of Fullerton Dental Assistant School, to satisfy their coronal polish certification requirements.

The coronal polishing procedure will consist of the removal of plaque and extrinsic stains by a rotating rubber cup, brush and polishing paste and will be done under the direct supervision of a licensed dentist (the “polishing procedure”). I understand that a dental assistant does not diagnose illness, disease, or any other physical or mental disorder. As such, the dental assistant prescribes neither medical treatment nor pharmaceuticals. It has been made very clear to me this polishing procedure is not a complete prophylactic (teeth cleaning) procedure.

This polishing procedure is not being administered to treat or diagnose any current or pre-existing ailment or injury. Because certain dental procedures should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions.

I also understand that the dental assisting student identified above is a student in training and is not a licensed or registered dental assistant, dentist, doctor or nurse. I recognize that Fullerton Dental Assistant School supports this polishing procedure in order to provide dental assisting students with practical hands-on experience and that I am receiving this polishing procedure at no charge in light of these facts. No oral statements contrary to this disclosure have been stated to me.

In consideration of the dental assisting student identified above administering the polishing procedure, I, for myself, my heirs, executors, administrators and assigns:

1.Release such student and Fullerton Dental Assistant School its affiliates, servants, agents or employees from any claims, demands, damages, actions or causes of action arising out of or in consequence of any loss, injury or damage to my person or property incurred in connection with the polishing procedure, notwithstanding that any such loss, injury or damage may have arisen by reason of the negligence of Fullerton Dental Assistant School, its affiliates, students, servants, agents or employees;

2.Fully understand the risks and dangers of the polishing procedure and accept these risks and dangers entirely at my own risk;

3.Fully understand that my participation in the polishing procedure program is entirely voluntary;

4.Agree that Fullerton Dental Assistant School shall not be liable to me for: (a) any loss (including loss by theft) or damage to my property, or the property of others, which property shall be my sole risk; or (b) any injury to, or death of, any persons including me, in each case resulting from or in connection with the polishing procedure or the Fullerton Dental Assistant School, or any of its employees’, students’ or agents’ acts or omissions;

5.Agree to indemnify the Fullerton Dental Assistant School, its affiliates, servants, agents or employees from any claims or demands which might be made against the Fullerton Dental Assistant School arising out of or in consequence of the polishing procedure;

6.Represent that I am the full age of eighteen (18) years or older

BY SIGNING THIS AGREEMENT, I AGREE TO ACCEPT ALL RISK AND RESPONSIBILITY RELATING TO THE POLISHING PROCEDURE.

Coronal Polishing Patient Health History

Date Of Birth

Your Physician’s Name

Your Physician’s Address:

Briefly describe your general health

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

Epilepsy

Yes

Thyroid Disease

Yes

Hepatitis

Yes

Diabetes

Yes

Liver Disease

Yes

Stroke

Yes

Heart Attack

Yes

Venereal disease

Yes

Anemia

Yes

Mumps

Yes

Rheumatic Fever

Yes

Emotional Disease

Yes

Measles

Yes

Have you been examined by a physician in the last year?

Yes

Has there been any change in your health in the last year?

Yes

Have you ever had surgery? (An operation)

Yes

Please describe

Have you gained or lost much weight recently?

Yes

Have you ever been treated for ear or eye trouble, other than corrective glasses?

Yes

Do you bleed for a long time when you cut yourself?

Yes

Have you ever had hives or a skin rash?

Yes

Have you ever been told you have heart trouble?

Yes

Do you get out of breath easily?

Yes

Do you have spells of dizziness?

Yes

Do your ankles ever become badly swollen?

Yes

Do you have high blood pressure?

Yes

Have you ever been told that you have a heart murmur?

Yes

Do you have any blood disorders?

Yes

Do you have asthma, hay fever, sinusitis or frequent sore throat?

Yes

Have you ever had tuberculosis, emphysema or other lung disease?

Yes

Do you have stomach trouble, frequent diarrhea or constipation?

Yes

Have you ever been told you have kidney or bladder trouble?

Yes

Have you ever had syphilis or gonorrhea?

Yes

Do you ever have fits, convulsions or seizures?

Yes

Do you have arthritis or joint trouble?

Yes

Are your joints often painfully swollen?

Yes

Have you had a general or local anesthetic?

Yes

Have you often had toothaches?

Yes

Do your gums bleed when you brush your teeth?

Yes

Do your gums itch when you brush your teeth?

Yes

Does it hurt when you chew?

Yes

Do you have any problems with your jaws?

Yes

Do you clench or grind your teeth?

Yes

Have you ever had an injury to your face, neck or jaw?

Yes

Do you suffer from frequent or severe headaches, neck or back pain?

Yes

Have you ever received x-ray or radiation therapy to the head or neck?

Yes

Do you have ear pain or pain in front of your ears?

Yes

Does your jaw feel tired after a big meal?

Yes

Must you chew on one side exclusively?

Yes

Is your sleep disturbed by pain in the head and neck region?

Yes

Are your daily activities or routines disturbed by pain in the head and neck region?

Yes

Do you consider yourself a nervous person?

Yes

Do you feel unhappy or depressed?

Yes

Are you easily upset?

Yes

Are you sensitive or allergic to any medicine?

Yes

Are you sensitive or allergic to any of the following?

Penicillin

Yes

Novocaine

Yes

Aspirin

Yes

Iodine

Yes

Codeine

Yes

Sleeping Pills

Yes

Other

Do you smoke or use tobacco?

Yes

Do you drink alcohol daily?

Yes

WOMEN — Are you pregnant?

Yes

WOMEN – Are you in or have passed through menopause (change of life)?

Yes

When did you last have radiographs of your teeth (Full Mouth X-rays — 18-20 images) taken? (Month/Year)

List all Prescription and Non-Prescription Drugs Taken or Used in the Past 3 Months:

List all Hospitalizations for Any Reason:

Date / Time

Patient’s Signature

Sign Here

Coronal Polish – Consolidated Patient Form – Medical History & Consent

Section 1 – Patient Information

Patient’s Date Of Birth

Patient’s First Name

Patient’s Last Name

Student’s First Name

Student’s Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician’s Name

Physician’s Phone

Section 2 – Medical/Dental Health History

Heart Condition (murmur, valve, attack)

Yes

Diabetes

Yes

Epilepsy/Seizures

Yes

Asthma/Respiratory Issues

Yes

Tuberculosis

Yes

Hepatitis/Liver Disease

Yes

Bleeding Disorders

Yes

Allergies (Penicillin, Codeine, etc.)

Yes

Pregnancy (if applicable)

Yes

List current medications:

Emergency contact:

When was your last full set of dental x-rays (18 images)?

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

Signature

Sign Here

Call Us: 714-882-5518

Coronal Polishing
Patient Consent & Health History

Section 1 – Patient Information

Section 2 – Medical/Dental Health History

Section 3 – Consent & Release

Section 4 – Acknowledgement & Signatures

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Call Us: 714-882-5518

Coronal Polishing Patient Consent & Health History

Section 1 – Patient Information

Section 2 – Medical/Dental Health History

Section 3 – Consent & Release

Section 4 – Acknowledgement & Signatures

Coronal Polishing
Patient Consent & Health History