Updated Medical
Health History Form

Coronal Polish Patient Forms

Coronal Polishing Patient Consent Form

Patient’s Name

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.

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:

Patient’s Profile

Address, including: City, State & Zip

Patient’s Phone Number

Dentist’s Name

Dentist’s Address

Dentist’s Phone Number

The medical health history above has been reviewed and approved.

Medical Health Statement

I, the patient hereby declare that to the best of m 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, the patient, hereby give my permission for a pit and fissure sealant to be performed on me as part of clinical requirement for pit and fissure sealant certification course.

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 heirs may have nor or in the future against its principles and/or agents, arising out of

or resulting from my voluntary participation as a patient in the dental trainee program for pit and fissure sealant course.

I have read and I understand the terms of this agreement.

Pit & Fissure Sealant Criteria Form

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. (Medical Health History Form will be completed prior to treatment and approved by 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 (1) 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 sealed.

Call Us: 714-882-5518

Updated Medical
Health History Form

Get a job in a dental office while you’re learning

We are the only school that issues certificates before graduation allowing students to get paid while attending the program.

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Courses

Contact

Call Us: 714-882-5518

Updated Medical Health History Form

Get a job in a dental office while you’re learning

We are the only school that issues certificates before graduation allowing students to get paid while attending the program.

Navigation

Courses

Contact

Updated Medical
Health History Form