A-B Tech Allied Dental Clinic
HIPAA Consent and Consent for Treatment
Our primary function is to train students to perform Dental Hygiene and/or Dental Assisting services for
patients in a professional, ethical and legal manner under the supervision of instructors and staff dentist.
I hereby give my consent to the faculty of A-B Tech Allied Dental Clinic to do any examination,
treatment planning, and professional services they may deem necessary for my optimum oral health. I
also consent to the use of any part of my patient chart or assessment for teaching purposes.
In agreeing to be a patient in the Dental Hygiene and/or Dental Assisting Clinic, I understand that the
primary purpose of the Clinic is for teaching students. I also understand that the clinic cannot be my
primary dental care provider and is unable to provide emergency dental care. It is my responsibility to
establish regular dental care with a dentist of my choice. Although a dental treatment plan may be
generated by a dentist at the teaching clinics, I understand that treatment will only be offered to selected
patients who first meet the educational needs of the students and second meet the personal needs of
patient. Therefore, none, part or all of the treatment plan may be utilized in the teaching clinics.
I further understand that I may or may not be re-appointed for recare (cleanings) or restorative dental
appointments. By initialing this paragraph I agree to and understand this statement.
________
(please initial )
As a teaching clinic patient I understand that it may take more than one appointment and that each
appointment will be approximately 2 ½ hours long. I agree to commit to this and to be responsible to
notify the clinic 24 hours in advance if I am unable to keep my scheduled appointments.
Dental Hygiene and/or Dental Assisting Teaching Clinic Policies have been presented and explained to
me. I understand that the procedures that may be performed are:
A.
B.
C.
D.
E.
F.
G.
H.
I.
A Complete Medical/Dental History
Vital Signs
Intra/ Extra Oral Exam
Dental Radiographs (as needed)
Plaque Indices
Homecare
Scaling and Selective Polishing
Calculus, Dental and Periodontal
Charting (as needed)
Fluoride Treatment Care
J.
K.
L.
M.
N.
O.
Impressions for Study Models
Use of Antimicrobials
Sonic/Ultrasonic Scaling
Pit and Fissure Sealants
Local / Topical Anesthetic
Photographs
P.
Nutritional Counseling
Q.
Care of Dental Appliances
R.
Restorative dental care
List________________
In consideration of the services provided by the Dental Hygiene Dental / Assisting Teaching Clinic, I
Hereby Release And Agree To Save Harmless A-B Tech Community College its trustees, instructors,
employees and students, and any other persons connected with the services, from any and all claims,
damages, and causes of action that may arise from provision of the services described above and from any
other care provided while I am a patient at the clinic.
This consent will remain in effect until I inform the A-B Tech Allied Dental Clinic in writing that I am
withdrawing my consent for any service.
Date ____________Name __________________________________ Signature ______________________
(If under age 18) Parent Name _______________________________ Signature _____________________
A-B Tech Allied Dental Clinic
HIPAA Consent and Consent for Treatment
Before starting treatment, we want you to be aware that our treatment area is a relatively open
arrangement. With this arrangement, efforts will be made to keep your health information confidential.
Examples of Disclosures for Treatment, Health Care Operations, and Instruction
1. We may use your health and dental information for teaching purposes. Your name will not be used.
2. We may leave a message on your answering machine/ voice mail, or with someone at
your residence or work place to confirm a scheduled appointment or to make an appointment.
3. We may use your information for treatment. For example: We may provide your physician
or Dentist information that will help us better care for you.
To the best of my knowledge the information given is accurate and I agree to both Treatment and HIPPA
Consents.
I authorize the release of any information necessary to initiate my dental care. I authorize and give
permission to leave voice messages on my home or cell phone concerning appointments and treatment. It
is understood that this information is confidential and will be released only to those with a justified need
to know.
List individual names below who may receive information.
.
Name __________________________ Relationship_____________________________
Name __________________________ Relationship_____________________________
Name __________________________ Relationship_____________________________
Other Uses or Disclosures
Business Associates: There are some services provided in our organization through volunteer dental
professionals. When these professionals perform services for our department, we require the business
associate to appropriately safeguard your information.
The Notice of Privacy Practices is a complete description of the rights of patients at the A-B Tech Dental
Clinics with respect to the patients’ information and how patient information is protected. I have been
given the opportunity to review the Notice of Privacy Practices prior to signing this consent.
By signing below, I am stating I have received the Notice of Privacy Practices of A-B Tech Allied Dental
Clinics.
Pa
(or authorized representative)