Fillable Accessibility-treatment-consent Treatment Consent Form

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Accessibility-treatment-consent Treatment Consent Form

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TREATMENT CONSENT FORM
Dental Hygiene/Attn: Clinic Receptionist
Health and Human Services Building 515
North Washington Square, Suite 107
Lansing, MI 48933
Reception Phone: (517) 483-1458 Program Office Phone: (517) 483-1457 FAX: (517) 483-9925
• Having read the Patient Information Form and the Patient Rights and Responsibilities Form, I verify that I
understand the information provided. I also understand the hazards and possible consequences involved
in dental care in the LCC Clinic. I hereby consent to such treatment and agree to hold Lansing Community
College, its agents, employees, and students, free and harmless from any claims, demands or suits for
damages from any injury or complications which may result from this treatment.
• I further authorize the Lansing Community College Dental Hygiene Program to perform whatever
preventative dental hygiene procedures and treatments are necessary for me as a patient, or for my
dependent child, who is a patient. (This also applies to any person who has legal guardianship over
another person.)
• I further authorize the college staff to use materials, including visual aids, pertaining to this case, for
educational purposes.
• I understand that no warranty or guarantee has been made to me as to a result of cure of dental disease.
I am aware that these preventative dental hygiene services performed in the clinic DO NOT TAKE THE
PLACE of a regular comprehensive dental exam with a dentist and that I should have regular check-up
examinations by a licensed dentist outside of being treated by the LCC Dental Clinic.
After reading the forms identified (Patient Information Form and Treatment Consent Form, Patient Rights and
Responsibilities Form, and The Health and Information Privacy Act (HIPAA) form), please initial below that you
understand each document.
Initial I have read the Patient Information and TreatmentConsent Form
Initial I have read the Patient Rights and ResponsibilitiesForm
Initial_____ I have read The Health and Information Privacy Act (HIPAA) Form
Please print your name, sign and date this document which indicates my commitment to the student’s learni
ng
experience. As stated on the Rights and Responsibilities Form, my intention is to attend all appointments and call
at least 48 hours in advance should I need to cancel my appointment so that the dental hygiene student can
secure another patient.
Printed Name of Patient / Date Signature of Patient (Parent or Guardian ofa Minor
Child or Legal Guardian of Other Individual)
Verified by: (Student or Faculty) / Date
Dental Clinic Personnel Only Sign Here
AUTHORIZATION FOR RELEASE OF DENTAL INFORMATION FORM
Dental Hygiene/Attn: Clinic Receptionist
Health and Human Services Building
515 North Washington Square, Suite 107
Lansing, MI 48933
Reception Phone: (517) 483-1458 Program Office Phone: (517) 483-1457 FAX: (517) 483-9925
The purpose of this form is to allow LCC Dental Hygiene Clinic, to release your confidential
dental information to a third party. An example of such a reason would include the mailing
of your radiographs to your private dentist or clinic. In order to provide us with your
authorization, per the HIPAA Policies of the Dental Hygiene Program, you must complete
the information listed below.
I,
authorize LCC Dental Hygiene Clinic to release dental information
to: (
Printed Name of Patient)
SEND BY MAIL OR ENCRYPTED EMAIL TO: SEND BY MAIL OR ENCRYPTED EMAILT O :
Dentist, Clinic, Institution, Etc. Dentist, Clinic, Institution, Etc.
Address or Email Address or Email
City, State, Zip Code City, State, ZipCode
Phone Number Phone Number
NOTE: Digital Films can be sent directly to dentist office. If patient is requesting Traditional films be sent,
duplicates will be sent and the original films will be kept at the LCC DH Clinic.
authorize LCC Dental Hygiene Clinic to release the following
Signature of Patient or Legal Guardian/ Date Verified by: (Student or Faculty) / Date Dental Clinic Personnel Only Sign Here
I,
information:
(Printed Name of Patient)
Any portion of my dental record (preferred)
Radiographs (Dental x-rays) only
Periodontal Charting only
Thi
s release is in effect from the time of your signing this document. However, it may be revoked by
you, the patient/guardian at any time, by providing verbal or written authority to us.
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Accessibility-treatment-consent Treatment Consent Form

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Completed 15 February 2020

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