DENTAL ASSISTING
Program Requirements Checklist & Forms
In order to participate in the Dental Assisting course, participants must complete and return the following
requirements two weeks prior to the first class. Participants who fail to return all documents by that date
may jeopardize their seat in the class.
Prerequisite
Participants must be at least eighteen years of age and possess either a GED or high school diploma.
Requirements Checklist (all forms are included in this electronic packet)
Completed Health History form
Signed Consent form*
Signed Waiver & Release form*
Permission for the Release of Student Information
Photo Release form*
* These forms require a witness signature and can be signed by any one of your personal contacts. Forms do not
need to be notarized.
Student Requirements (associated costs are the responsibility of the student)
Uniform: Scrub tops/bottoms (suggest two pair of each), can be any color, print or solid (nothing potentially
offensive), must be professional in appearance (worn at waist and cover mid-section)
Uniform shoes – all white leather sneakers with white shoelaces
Safety glasses with side shields
Lab coat, any color (optional)
CPR for Healthcare Providers certification – required two weeks prior to last scheduled class
Mandatory Orientation
A mandatory orientation will be held the Thursday prior to the first class from 6 – 8 p.m. in the Dental Lab, Room 312.
Department policies and procedures will be reviewed at that time.
All requirements must be completed two weeks prior to the first class.
Please mail completed documents to:
Program Manager, Dental Assisting
Fowler Family Southside Center, Room 510
511 E. Third Street
Bethlehem, PA 18015
Questions?
Please call 610-332-6585 or e-mail healthcare@northampton.edu.
Northampton Community College
Fowler Family Southside Center
511 East Third Street
Bethlehem, PA 18015
www.northampton.edu/cbi
ASA-PS Case Type:
 I  II  III
Medical Alert:
NORTHAMPTON COMMUNITY COLLEGE
DENTAL ASSISTING
DEPARTMENT HEALTH HISTORY
Name ____________________________________ Home Phone _________________ Cell Phone ________________
Age _____ Date of Birth ___________________ Business Phone _________________
Street #/Address ____________________________________ City __________________ State _____ Zip____________
Sex M
F Marital Status ______________ Occupation _______________________ Height _____ Weight _____
Emergency Contact __________________________ Contact Phone #__________________
Family Dentist’s Name ________________________________Address _____________________________________
#/ Street/ City/ State/ Zip Code
Medical Assistance/Dental HMO carrier and card number ___________________________________________________
What is the reason for your visit today? _______________________________________________________________
General Medical History
How do you rate your overall health? __________________________________________________________________
Please circle Y for Yes or N for No where indicated:
Y N Are you under the care of a physician? If YES, why? Date of last visit?
Comments:
Name/Address of your Physician:
Y N Do you have a major illness? If YES, what is the illness?
Y N Have you been hospitalized or have you had an operation in the past 5 years?
Medications - Please check () whether you are PRESENTLY taking any of the following medications; for all
medications you are presently taking, please list the medication’s name on the appropriate line below.
______ Antibiotics_________________________________________________________________________________
______ Anticoagulants (bloodthinners)_________________________________________________________________
______ Medicine for high blood pressure_______________________________________________________________
______ Medication for heart disease___________________________________________________________________
______ Nitroglycerin_______________________________________________________________________________
______ Cortisone/prednisone (any other steroids)_________________________________________________________
______ Medication for asthma________________________________________________________________________
______ Antidepressants, Anti Anxiety medications________________________________________________________
______ Medication for thyroid disorder ________________________________________________________________
______ Insulin, medication for diabetes_________________________________________________________________
______ Antihistamines______________________________________________________________________________
______ Radiation/Cancer chemotherapeutic______________________________________________________________
______ Medication for gastric reflux or stomach ulcers_____________________________________________________
______ Oral contraceptive OR hormone replacement therapy________________________________________________
______ Over-the-counter medication, i.e., Aspirin, Tylenol, Advil____________________________________________
______ Natural or herbal preparations, vitamins___________________________________________________________
______ Other (please specify)_________________________________________________________________________
If you are on a special diet prescribed by your doctor please explain:
__________________________________________________________________________________________________
Are you allergic to or have you had a reaction to:
YES
NO


















Don’t If YES, describe the type of allergic reaction experienced on the lines below.
Know

Local/topical anesthetics _______________________________________________________








Penicillin or other antibiotics, i.e., Sulfa ___________________________________________
Aspirin _____________________________________________________________________
Barbiturates, sedatives, or sleeping pills ___________________________________________
Latex ______________________________________________________________________
Codeine/narcotics _____________________________________________________________
Hay fever/seasonal allergies _____________________________________________________
Food _______________________________________________________________________
Other _______________________________________________________________________
Circle Y if you have experienced, or circle N if you have not experienced, any of the following conditions:
Cardiovascular
Y N Angina
Y N Artificial heart valve
Y N Chest pain upon exertion
Y N Congenital heart defect
Y N Congestive heart failure
Y N Coronary artery disease
Y N Heart attack (MI)
Y N High blood pressure
Y N Pacemaker or defibrillator
Y N History of infective endocarditis
Y N Cardiac transplant
Comments:
Respiratory
Y N Asthma
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Allergies, hay fever, sinus troubles
Bronchitis
Cough up blood
Emphysema
Persistent cough, i.e., greater than 3 weeks
Pneumonia
Shortness of breath/breathing difficulties
Tuberculosis or exposure to TB
Central Nervous System/Neurological
Y N Alzheimer’s disease
Y N Aneurysm
Y N Apprehension, anxiety or depression
Y
Y
Y
Y
Y
Y
Y
Y
Comments:
Comments:
N
N
N
N
N
N
N
N
Fainting/dizzy spells
Frequent or severe headaches
Multiple sclerosis
Parkinson’s disease
Psychiatric disorders and treatment
Seizures, convulsions or epilepsy
Stroke or transient ischemic attacks
Attention Deficit Disorder (ADD) or
ADHD
Y N Autism Spectrum Disorders
Y N Down Syndrome
Y N Mental Retardation
Gastrointestinal
Y N Cirrhosis of the liver
Y N Colitis
Y N Gastric reflux
Y N Hepatitis, liver disease
Y N Ulcers, stomach problems
Musculoskeletal
Y N Artificial joint, i.e., hip, knee
Y
Y
Y
Y
N
N
N
N
Comments:
Comments:
Systemic lupus erythematosus
Osteoarthritis
Osteoporosis
Rheumatoid arthritis
Endocrine
Y N Diabetes
 Type 1  Type 2
Y N Frequent thirst or urination
Y N Thyroid gland disorder
Women only: Are you pregnant? Y N
Comments:
Hematologic
Y N Anemia
Y N Blood transfusion before 1992
Y N Excessive/abnormal bleeding
Y N Unexplained bruising
Y N Hemophilia or problems with blood clotting
Y N HIV infection or AIDS
Y N Leukemia
Comments:
Genitourinary
Y N Kidney problems
Y N Renal dialysis or renal transplant
Comments:
Y N Are there any other conditions that were not listed that you have experienced? If yes, describe.
__________________________________________________________________________________________________
Social History
Y N Do you use tobacco in any form (smoking, chew, snuff)?
If YES, in what form?
How frequently do you use tobacco?
Comments:
How long have you used tobacco?
Y N If you smoke or use chewing tobacco, have you ever tried to quit?
If yes, approximately how many times have you tried to quit?
When did you last try to quit?
If you use tobacco, how interested are you in quitting?
 Very Interested
 Somewhat Interested
 Not Interested
Y N Have you ever been treated for drug/alcohol related problems?
Y N Do you use or have you used recreational or street drugs?
Y N Do you consume alcohol? Type
Frequency/Quantity
Y N Do you feel unsafe at home?
Dental History
When was your last visit to a dental office? _____________________ What was done? __________________________
Comments:
Y N Do your gums bleed when you brush?
Y N Are your teeth sensitive to cold, hot, sweets or pressure?
Y N Do you have a sore jaw, earaches or neck pains?
Y N Have you had any periodontal (gum) treatments?
Y N Do you wear a removable dental appliance?
Have you had a problem associated with any previous dental treatment? If so, please describe
_____________________________________________________________________________________________
I hereby certify that the above information is correct to the best of my knowledge. I will not hold Northampton
Community College responsible for any situation which arises from lack of disclosure or misinformation.
Client’s Signature _____________________________________________ Date __________________
or Parent/Guardian’s Signature ________________________________ Date __________________
DA Student’s Signature _________________________________________ Date __________________
Faculty Signature ______________________________________________ Date __________________
DENTAL ASSISTING PROGRAM
DENTL200
CONSENT FORM FOR ACTING AS OR TREATING A PEER CLINICIAN
By my signature below, I acknowledge and agree that I will be receiving non-invasive
dental services and also collecting data in the laboratory portion of the Dental Assisting
Program for which I am registered.
__________________________________________
Print Full Name
Date:____________
__________________________________________
Signature
Date:____________
__________________________________________
Witness
Date:____________
DENTAL ASSISTING
WAIVER AND RELEASE FROM LIABILITY
IN CONSIDERATION of being allowed to participate in any activity or training program affiliated
with Northampton Community College and intending to be legally bound hereby, the
undersigned:
Acknowledges and fully understands that each participant will be engaging in activities that
involve collecting data and practicing dental assisting skills on each other and the risks thereof.
Further, the undersigned acknowledges and fully understands that there may be other risks not
known to the College.
The undersigned acknowledges and assumes all the foregoing risks and accepts personal
responsibility for any and all damages of whatever kind, name or nature in any manner arising
out of or in connection with the undersigned’s participation in the activity or training program.
The undersigned forever releases, acquits, discharges, indemnifies and holds harmless the
College and all its agents, officers and employees and if applicable, the other participants in the
program and owners and lessors of premises used to conduct the program from and all causes
of action, including personal injury, illness, death and property damage, costs, charges, claims,
demands and liabilities of whatever kind, name or nature in any manner arising out of or in
connection with the undersigned’s participation in the activity or training program.
THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE AND UNDERSTANDS THAT
HE/SHE HAS GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND DOES HEREBY
ACKNOWLEDGE THAT HE/SHE IS SIGNING IT VOLUNTARILY.
STUDENT Print Name____________________________________________________________________
First
Middle
Last
STUDENT SIGNATURE: ______________________________________ Date: _______________________
WITNESS SIGNATURE: ______________________________________ Date: _______________________
Revised: May 2016
PERMISSSION FOR THE RELEASE OF STUDENT INFORMATION
I hereby give Northampton Community College, Dental Assisting course permission to release
information to:
The following categories may be released for the purpose of referral or information:
Test Data
Yes
No
Personal Information
Yes
No
Academics
Yes
No
As of ________________________, I have been a resident of Pennsylvania without interruption for the past
2 years.
Signature_______________________________________
Date_________________
I authorize Northampton Community College to release a copy of my competencies to prospective
employers who request training information.
Signature:
Print Name:
Date:
PHOTOGRAPHY RELEASE
For and in consideration of my engagement as a model by Northampton Community College, Hereafter
referred to as NCC, I hereby give NCC, its legal representatives and assigns, those for whom NCC is
acting, and those acting with its permissions, or its employees, the right and permission to copy-right
and/or use, reuse and/or publish, and republish photographic pictures or portraits of me, or in which I
may be distorted in character, or form, in conjunction with my own or a fictitious name, on
reproductions thereof in color, or black and white made through any media by NCC, for any purpose
whatsoever; including the use of any printed matter in conjunction therewith.
I hereby waive any right to inspect or approve the finished photograph or advertising copy or printed
matter that may be used in conjunction therewith or to the eventual use that I might be applied.
I hereby release, discharge and agree to save harmless NCC, its representatives, assigns, employees or
any person or persons, corporation or corporations, acting under its permission or authority, or any
person, persons, corporation or corporations, for whom he/she might be acting, including any firm
publishing and/or as a result of any distorting, blurring, or alteration, optical illusion, or use in the
taking, processing or reproduction of the finished product, its publication or distribution of the same,
even should the same subject me to ridicule, scandal, reproach, scorn or indignity.
I hereby warrant that I am 18 years of age or older, and competent to contract in my own name insofar
as the above is concerned.
I have read the foregoing release, authorization and agreement, before affixing my signature below,
and warrant that I fully understand the contests thereof.
Program or Course:
Dental Assisting
Print Name:
Signature:
Date:
Parent or Guardian
(if under age 18)
Date:
Address:
Daytime Phone:
Witness:
(
)
Date:
C:\Users\jkszak\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\XE2GBY6Z\Photo Release Local
Anesthesia.doc