Preclinic Techniques Week 12 application for dental treatment

Treatment Paragraph 1

patient consents to be treated by student under the supervision of licensed faculty

Treatment paragraph 2 (3)

- all of my dental work may not be completed

- i will be available 1/2 day per week for appointments

- the results of treatment may not be to my complete satisfaction

appointments paragraph 1

if i fail to pay, keep appointments or cancel appointments (less than 24 hours before) I may be dismissed as a patient

medical central pharmacological history paragraph 1

all the responses I provide are truthful

medical central pharmacological history paragraph 2 (4)

- if an accidental exposure to the patients blood occurs, a request top be tested may be made

- the pt. has the right to refuse without risking their status as a pt at the COD

- testing done at no charge

-test results will remain confidential

records/tests paragraph 1

consent to photos/x-rays, impressions, etc. for the purpose of diagnosing and treatment planning

records/tests paragraph 2 (2)

-pt.'s original record, films, and diagnostic aids are the property of the COD

-copies will be provided upon request

records/tests paragraph 3

I have received a copy of the UNMC privacy notice

3rd party payment (insurance, Benefit) paragraph 1

i request the COD to submit my insurance claim or preauthorization to my insurance carrier or the other benefit program

education paragraph 1

i will allow students to use data from my records, x-rays, models for an educational project (case study) as long as I am not identified in any way

education paragrpah 2

I will allow professional visitors, prospective students to observe while care is being provided

patient care quality assurance paragraph 1

the COD surveys patients regarding the quality of care they received and/or offers pt.'s to participate in quality of care clinical examinations