Informed Consent for Dental Hygiene Treatment 

Welcome to the Vermont State Colleges. We are pleased that you are interested in bettering your oral health at the Vermont State University Dental Hygiene Clinic and we wish to provide you with thorough treatment.  The clinic policies are outlined for your review. We will be happy to provide additional information regarding our policies and procedures if needed. 

  • The procedures performed at the Vermont State University Dental Hygiene Clinic do not replace dental examinations by your regular dentist. The program advocates regular examinations and other services by your regular dentist.                                  
  • The Vermont State University Dental Hygiene program practices and employs current infection control policies with all aspects of patient care.   
  • Appointments are 2 to 3 hours in length. Treatment is provided by dental hygiene students and supervised by faculty. As this is an educational facility, patients should expect to have multiple appointments to complete treatment.                            
  • Appointment changes must be made at least 48 hours prior to your appointment time, except in the case of an emergency. A history of broken appointments will prohibit provision of future dental hygiene care at the Vermont Tech Dental Hygiene Clinic.        
  • A fee will be collected after the first appointment. Services include complete dental hygiene care, radiographs if needed, fluoride and other treatment deemed necessary.  A copy of your x-rays will be e-mailed to your dental provider upon your request. Once treatment has begun no refunds are given unless there are extenuating circumstances. Patients must submit their own dental insurance forms to their insurance company.  Upon request, we will provide you with the necessary insurance codes to assist you in the process.                                                                       
  • It is possible that during or after treatment in our clinic that a restoration (filling), crown/cap, veneer, splint, orthodontic material, bonding and bonded wires, retainers, sealants, dentures and any materials a dentist may have placed in the mouth, as well as tooth structure may inadvertently chip, crack, debond, fracture, fail, break or fall out. These can be consequences of standard dental hygiene care. The Vermont State University and the Vermont State University Dental Hygiene Department does not assume any responsibility or liability for replacement, repair or any possible consequences of the previously mentioned items. It is possible that during and after treatment in our clinic you may experience pain/soreness of your gums and you may experience mild bleeding. It is possible some patients may have increased sensitivity, swelling/gum abscesses or cold sores.  These can be conditions normally associated with standard dental hygiene treatment and the Vermont State University and the Department of Dental Hygiene clinic assumes no responsibility or liability for these conditions.  
  • It is possible that infections and contagions may spread during dental treatment, despite the use of current preventive practices. By signing this document, I acknowledge the risks of infection or contagion during dental treatment and assume all responsibility and liability if these conditions develop, releasing Vermont State University and the Vermont State University Dental Hygiene Clinic from all responsibility or liability.   
  • For children under the age of 18, a parent or guardian must sign the medical history form and authorize treatment at the initial appointment and all future appointments. Parents are requested to remain in the reception room during their child’s appointment. All children in the reception room must be accompanied and supervised by an adult at ALL times so we recommend that you schedule your personal appointment at a different time than your child’s as your care will take longer. Vermont State University is not responsible for children left unattended by a parent.   
  • I permit the faculty to photograph all or part of my treatment for the advancement of dental hygiene education without financial reward to myself.      
  • I hereby authorize the Vermont State University to provide procedures which are recommended for optimal oral health. These procedures include, but are not limited to, prophylaxis, oral health instruction, x-rays, fluoride treatments, periodontal charting, nutritional/tobacco counseling and sealants. Treatment may be denied if we are unable to perform all procedures deemed necessary for treatment. I understand that should I need medical attention due to a medical emergency or for other reasons, I will be responsible for those medical expenses, including transport by ambulance and that dental hygiene services may be delayed. 
  • The nature of dental work may result in an accidental exposure or exchange of oral secretions or blood between patients and providers. Should this unlikely event take place post exposure blood testing for Hepatitis B/C and HIV is necessary and any costs not covered by the patient’s insurance carrier will be paid by the Vermont State University.