Local Anesthesia For Licensed Dental Hygienists
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1 Local Anesthesia For Licensed Dental Hygienists Program Requirements Checklist & Forms In order to participate in the Local Anesthesia for License Dental Hygienists course, participants must complete and return the following requirements two weeks prior to the first class. Participants who fail to return all the documents by that date, will be withdrawn from the class. Please note: participants cannot be pregnant at the time of this class due to the giving and receiving of local anesthesia during the class. Requirements Checklist All forms are included in this electronic packet. Copy of your current Pennsylvania Dental Hygiene License. Copy of your current CPR Healthcare Provider Certification. Proof of professional liability insurance. Completed Health History Form. Signed and completed Consent Form for Giving and Receiving Local Anesthesia (signed & witnessed*). Completed Waiver and Release Form (signed & witnessed*). Completed Permission for the Release of Student Information Form. Completed Photo Release form (signed & witnessed*). Enroll in the course. Register online at northampton.edu/lifelearn. Please reference course code DENTL103. Course fee is due at the time of registration via credit card. Print and review the Student Handbook. Purchase textbook, Local Anesthesia for Dental Hygienist by Demetra Daskalos Logothetis (ISBN ) prior to first class. * The forms that are marked signed & witnessed require a witness signature and can be signed by anyone within your dental practice. You do not need to have these forms notarized. All requirements must be completed two weeks prior to the first class. Please mail completed documents to: Program Manager, Dental Anesthesia Fowler Family Southside Center, Room E. Third Street Bethlehem, PA Questions Please call or healthcare@northampton.edu. Northampton Community College Fowler Family Southside Center 511 East Third Street Bethlehem, PA
2 ASA-PS Case Type: I II III NORTHAMPTON COMMUNITY COLLEGE DENTAL HYGIENE DEPARTMENT HEALTH HISTORY Medical Alert: Name Home Phone Cell Phone Age Date of Birth Business Phone Street #/Address City State Zip Sex M F Marital Status Occupation Height Weight Emergency Contact Contact Phone # Family Dentist s Name Address #/ Street/ City/ State/ Zip Code Medical Assistance/Dental HMO carrier and card number What is the reason for your visit today? General Medical History How do you rate your overall health? Please circle Y for Yes or N for No where indicated: Y N Are you under the care of a physician? If YES, why? Date of last visit? Name/Address of your Physician: Y N Do you have a major illness? If YES, what is the illness? Y N Have you been hospitalized or have you had an operation in the past 5 years? Medications - Please check ( ) whether you are PRESENTLY taking any of the following medications; for all medications you are presently taking, please list the medication s name on the appropriate line below. Antibiotics Anticoagulants (bloodthinners) Medicine for high blood pressure Medication for heart disease Nitroglycerin Cortisone/prednisone (any other steroids) Medication for asthma Antidepressants, Anti Anxiety medications Medication for thyroid disorder
3 Insulin, medication for diabetes Antihistamines Radiation/Cancer chemotherapeutic Medication for gastric reflux or stomach ulcers Oral contraceptive OR hormone replacement therapy Over-the-counter medication, i.e., Aspirin, Tylenol, Advil Natural or herbal preparations, vitamins Other (please specify) If you are on a special diet prescribed by your doctor please explain: Are you allergic to or have you had a reaction to: YES NO Don t If YES, describe the type of allergic reaction experienced on the lines below. Know Local/topical anesthetics Penicillin or other antibiotics, i.e., Sulfa Aspirin Barbiturates, sedatives, or sleeping pills Latex Codeine/narcotics Hay fever/seasonal allergies Food Other Circle Y if you have experienced, or circle N if you have not experienced, any of the following conditions: Cardiovascular Y N Angina Y N Artificial heart valve Y N Chest pain upon exertion Y N Congenital heart defect Y N Congestive heart failure Y N Coronary artery disease Y N Heart attack (MI) Y N High blood pressure Y N Pacemaker or defibrillator Y N History of infective endocarditits Y N Cardiac transplant
4 Respiratory Y N Asthma Y N Allergies, hay fever, sinus troubles Y N Bronchitis Y N Cough up blood Y N Emphysema Y N Persistent cough, i.e., greater than 3 weeks Y N Pneumonia Y N Shortness of breath/breathing difficulties Y N Tuberculosis or exposure to TB Central Nervous System/Neurological Y N Alzheimer s disease Y N Aneurysm Y N Apprehension, anxiety or depression Y N Fainting/dizzy spells Y N Frequent or severe headaches Y N Multiple sclerosis Y N Parkinson s disease Y N Psychiatric disorders and treatment Y N Seizures, convulsions or epilepsy Y N Stroke or transient ischemic attacks Y N Attention Deficit Disorder (ADD) or ADHD Y N Autism Spectrum Disorders Y N Down Syndrome Y N Mental Retardation Gastrointestinal Y N Cirrhosis of the liver Y N Colitis Y N Gastric reflux Y N Hepatitis, liver disease Y N Ulcers, stomach problems Musculoskeletal Y N Artificial joint, i.e., hip, knee Y N Systemic lupus erythematosus Y N Osteoarthritis Y N Osteoporosis Y N Rheumatoid arthritis Endocrine Y N Diabetes Type 1 Type 2 Y N Frequent thirst or urination Y N Thyroid gland disorder Women only: Are you pregnant? Y N
5 Hematologic Y N Anemia Y N Blood transfusion before 1992 Y N Excessive/abnormal bleeding Y N Unexplained bruising Y N Hemophilia or problems with blood clotting Y N HIV infection or AIDS Y N Leukemia Genitourinary Y N Kidney problems Y N Renal dialysis or renal transplant Y N Are there any other conditions that were not listed that you have experienced? If yes, describe. Social History Y N Do you use tobacco in any form (smoking, chew, snuff)? If YES, in what form? How frequently do you use tobacco? How long have you used tobacco? Y N If you smoke or use chewing tobacco, have you ever tried to quit? If yes, approximately how many times have you tried to quit? When did you last try to quit? If you use tobacco, how interested are you in quitting? Very Interested Somewhat Interested Not Interested Y N Have you ever been treated for drug/alcohol related problems? Y N Do you use or have you used recreational or street drugs? Y N Do you consume alcohol? Type Frequency/Quantity Y N Do you feel unsafe at home? Dental History When was your last visit to a dental office? What was done? Y N Do your gums bleed when you brush? Y N Are your teeth sensitive to cold, hot, sweets or pressure? Y N Do you have a sore jaw, earaches or neck pains? Y N Have you had any periodontal (gum) treatments? Y N Do you wear a removable dental appliance? Have you had a problem associated with any previous dental treatment? If so, please describe I hereby certify that the above information is correct to the best of my knowledge. I will not hold Northampton Community College responsible for any situation which arises from lack of disclosure or misinformation. Client s Signature Date or Parent/Guardian s Signature Date DH Student s Signature Date Faculty Signature Date
6 LOCAL ANESTHESIA FOR LICENSED DENTAL HYGIENISTS DENTL103 CONSENT FORM FOR GIVING AND RECEIVING LOCAL ANESTHESIA By my signature below, I acknowledge and agree that I will be receiving local anesthesia and also giving local anesthesia in the clinical portion of the Local Anesthesia for Licensed Dental Hygienists class for which I am registered. I also confirm that I will not be pregnant during the dates of this class. If you are pregnant, you must withdraw from the class. Print Full Name Date: Signature Date: Witness Date:
7 LOCAL ANESTHESIA FOR LICENSED DENTAL HYGIENISTS WAIVER AND RELEASE FROM LIABILITY IN CONSIDERATION of being allowed to participate in any activity or training program affiliated with Northampton Community College and intending to be legally bound hereby, the undersigned: Acknowledges and fully understands that each participant will be engaging in activities that involve injecting each other with local dental anesthesia and the risks thereof. Further, the undersigned acknowledges and fully understands that there may be other risks not known to the College. The undersigned acknowledges and assumes all the foregoing risks and accepts personal responsibility for any and all damages of whatever kind, name or nature in any manner arising out of or in connection with the undersigned s participation in the activity or training program. The undersigned forever releases, acquits, discharges, indemnifies and holds harmless the College and all its agents, officers and employees and if applicable, the other participants in the program and owners and lessors of premises used to conduct the program from and all causes of action, including personal injury, illness, death and property damage, costs, charges, claims, demands and liabilities of whatever kind, name or nature in any manner arising out of or in connection with the undersigned s participation in the activity or training program. THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE AND UNDERSTANDS THAT HE/SHE HAS GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND DOES HEREBY ACKNOWLEDGE THAT HE/SHE IS SIGNING IT VOLUNTARILY. PARTICIPANT Print Name First Middle Last Signature Date WITNESS Signature Date
8 PERMISSSION FOR THE RELEASE OF STUDENT INFORMATION I, hereby give (Please print name) Northampton Community College, Local Anesthesia for Licensed Dental Hygienists Program Permission to release information to: The following categories may be released for the purpose of referral or information (circle one): Test Data: Yes No Personal Information: Yes No Academics: Yes No REQUIRED: As of, I have been a resident of Pennsylvania without interruption for the past 2 years. Today s Date: Signature Date I authorize _Northampton Community College, Local Anesthesia for Licensed Dental Hygienists Program to release a copy of my competencies to prospective employers who request training information. Date Signature
9 PHOTOGRAPHY RELEASE For and in consideration of my engagement as a model by Northampton Community College, Hereafter referred to as NCC, I hereby give NCC, its legal representatives and assigns, those for whom NCC is acting, and those acting with its permissions, or its employees, the right and permission to copy-right and/or use, reuse and/or publish, and republish photographic pictures or portraits of me, or in which I may be distorted in character, or form, in conjunction with my own or a fictitious name, on reproductions thereof in color, or black and white made through any media by NCC, for any purpose whatsoever; including the use of any printed matter in conjunction therewith. I hereby waive any right to inspect or approve the finished photograph or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that I might be applied. I hereby release, discharge and agree to save harmless NCC, its representatives, assigns, employees or any person or persons, corporation or corporations, acting under its permission or authority, or any person, persons, corporation or corporations, for whom he/she might be acting, including any firm publishing and/or as a result of any distorting, blurring, or alteration, optical illusion, or use in the taking, processing or reproduction of the finished product, its publication or distribution of the same, even should the same subject me to ridicule, scandal, reproach, scorn or indignity. I hereby warrant that I am 18 years of age or older, and competent to contract in my own name insofar as the above is concerned. I have read the foregoing release, authorization and agreement, before affixing my signature below, and warrant that I fully understand the contests thereof. Program or Course: Local Anesthesia for Dental Hygienists Print Name: Signature: Parent or Guardian (if under age 18) Date: Date: Address: Daytime Phone: ( ) Witness: Date:
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