LARA/BPL-DENTPATIENT (10/18)
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disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
PATIENT PROTECTION FORM
Authority: 1978 PA 368
For each setting in which participants are treated by either a clinician or participants, provide the following information
(responses should apply to all clinical sites used.)
List operator equipment available:
List methods used to ensure sterile techniques:
Describe the provisions available for emergency in the following situations. In describing the provisions, include available
facilities, equipment, personnel, and location in relation to the course sites.
Medical Emergencies:
Dental Procedure Emergencies:
Prior to treatment in continuing education activities, indicate how participants are informed of the training situation and the arrangements
for follow-up care:
Who is responsible for obtaining informed consent from the patient?
Describe what arrangements are made regarding preoperative examination and preparation:
Describe what arrangements are made to assure postoperative (follow-up) care is provided:
Prior to a course, how do you asses the participant’s ability to assimilate instructions and perform the treatment technique(s) being taught?
What arrangements are made concerning liability protection for instructors and participants?
Are participants warned of the hazards of using limited knowledge in integrating new techniques into their practice?
Describe any follow-up contact the sponsor has with participants following courses in which new patient treatment techniques were
practiced/learned:
___________________________________________________ ____________________________________
Sponsor Signature Date
