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
• I further authorize the college staff to use materials, including visual aids, pertaining to this case, for
• 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
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