Mountain Area Health Education Center 121 Hendersonville Road. Asheville, NC PHONE: (828) FAX: (828)
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1 Coronal Polishing Clinical Participation Consent Form Coronal Polishing for the DA II MAHEC I,, participant in the Coronal Polishing for the DA II Program to be held on November 3, 2018, do hereby consent to participate in the clinical component of the class and agree to be a patient for the clinical student partner. I understand that my teeth will be polished during the 4 hour clinical component. I acknowledge, understand and accept the following: My teeth will be polished utilizing a fine grit polishing paste. Exposure to a polishing paste will remove very slight enamel during the coronal polish process yet a fine grit polish paste will be used resulting in minimal removal of enamel layer. Alternative treatment includes using toothpaste during the coronal polish procedure instead of fine grit polishing paste. The polishing procedure will be supervised by a Clinical Instructor. I have completed a personal medical history and have no contraindications to participating in the Coronal Polish clinical component of the Coronal Polish Certification Program. I will contact Ed Coryell, DDS, ed.coryell@mahec.net to address any concerns or questions regarding the coronal polish treatment I have received. I hold MAHEC harmless for any injury or damage that may occur from the cited procedure/treatment received during the class/course. Signature
2 CORONAL POLISHING FOR THE DA II- CLASS PARTICIPANT MEDICAL HISTORY FORM Name: DOB: Age: Height: Weight: Gender: Male Female Reason for today s visit: Participate in Coronal Polishing class Primary Care Provider: ALLERGIES Are you allergic to any medicines (including any tape, iodine or latex) No Yes (If yes, please complete the allergy information below) Medications Type of Reaction you experience PAST SURGICAL HISTORY Type of Operation of Operation CURRENT MEDICATIONS Medication Dose Frequency Medication Dose Frequency SOCIAL HISTORY Yes No Do you smoke? If yes, how much per day and how many years? Have you ever smoked? If yes, start date/quit date? Do you drink alcohol? If yes, how much and how often? Do you do street/non-prescribed drugs? If yes, please specify. of your last Tetanus Shot? p.1/2
3 MEDICAL HISTORY (Please check only if a history exists for yourself or a family member) Self Family Relationship to you Self Family Relationship to you Arthritis Kidney Problems Asthma Liver Problems/Hepatitis Bleeding Disorder Lung Problems Cancer Neuro: Seizures, Epilepsy Diabetes Psychiatric Gastrointestinal STD Genitourinary/Prostate Skin Disorders Heart Problems Thyroid High Blood Pressure Other High Cholesterol Women Yes No Last Menses: Pregnant Hysterectomy Participant s Signature Today s (The information provided on this form is true and correct to the best of my belief) p.2/2
4 Certification of Dental Assisting Employment and Professional Liability Insurance Coverage Professional Liability Insurance: Course participants will be both recipients and providers of direct treatment procedures in laboratory portions of the course. MAHEC requires that you maintain professional liability coverage that extends to the training situation, outside of your dentist/employer's office, and under the supervision of an Eastern AHEC instructor. You may have your own professional liability insurance or you may be covered under a blanket policy provided by your dentist/employer. Full membership in the American Dental Assistants Association (ADAA) includes professional liability insurance coverage in a training situation. If you are covered under another policy, verify with the insurance company that coverage extends to the training situation. Some companies will write an endorsement to provide training coverage; other policies automatically provide coverage. Ask the insurance company to provide you with a Certificate of Insurance naming you as the insured or as an insured employee in your dentist/employer's office with coverage for training outside of the office. Any change in insurance status must be reported immediately to MAHEC. If you would like to become a member of the American Dental Assistants Association (ADAA), contact: American Dental Assistants Association 203 North LaSalle Street, Suite 1320 Chicago, IL (312) , fax (312) I understand that I must maintain dental assisting professional liability insurance coverage or I must be covered under a blanket professional liability insurance policy provided by my dentist/employer. I certify that I am covered for training purposes under the dental assisting professional liability coverage as indicated below. I understand that this form or a copy of my current American Dental Assistants Association full membership card must be provided to MAHEC prior to attending the Coronal Polishing course. Name of Registered Participant Name of Insured/Policy Holder Professional Liability Carrier Policy Number Period of Coverage: From/To Print Full Name of Dental Assistant Dental Assistant Signature/ Dentist/Employer Certification I certify that the above-named Dental Assistant is currently employed in my institution/dental practice and is covered for training situations outside my office under the professional liability insurance policy listed above. Printed Name of Dentist/Employer Dentist/Employer Signature/ Complete & return this certification form to MAHEC prior to attending the Coronal Polishing course. Scan/ to Rosalyn.wasserman@mahec.net or Fax to If you have questions contact Rosalyn Wasserman at
5 The North Carolina State Board of Dental Examiners has ruled that coronal polishing is a legal function for trained Dental Assistant II. To be accepted in MAHEC s Coronal Polishing course, the participant must submit documentation of status as a Dental Assistant II. Please indicate which training you completed to be classified as a Dental Assistant II. Verify successful completion by attaching documentation or having your employer sign below. Approved Education and Training Programs To be classified as a Dental Assistant II, an assistant must meet one of the following criteria: Successful completion of: 1. an ADA-accredited dental assisting program and current certification in CPR; or 2. one academic year or longer in an ADA-accredited dental hygiene program, and current certification in CPR; or Successful completion of: 1. full-time employment and experience as a chair side assistant for two years (3,000 hours) of the preceding five, during which period the assistant may be trained in any dental delivery setting and allowed to perform the functions of a Dental Assistant II under the direct control and supervision of a licensed dentist; 2. a 3-hour course in sterilization and infection control; 3. a 3-hour course in dental office emergencies; 4. radiology training consistent with G.S 90-29(c)(12) bi-laws of the North Carolina State Board of Dental Examiners; and 5. current certification in CPR; or Successful completion of the certification examination administered by the Dental Assisting National Board, and current certification in CPR I have attached documentation supporting the above classification as a Dental Assistant II. Participant Signature Participant s Printed Name AND I verify that my employee has completed the above requirements and is classified as a Dental Assistant II. Employer Signature Employer s Printed Name
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