Student Participation, Consent, Assumption of Risk, Release Of Liability Form

IMPORTANT: This form affects your legal rights. Please read it before signing.
 
1. Hands-on practice and consent. I voluntarily agree to take part in hands-on dental hygiene practice. I may perform procedures on classmates, and classmates may perform procedures on me, under instructor supervision. Procedures may include, as applicable, oral examination, instrumentation and scaling, ultrasonic instrumentation, polishing and radiographs. This is training, not complete dental care. Professional Learning Services LLC (“PLS”) will not provide a full dental examination, diagnosis, treatment plan, or follow-up care. I will obtain needed care from my own dentist or physician.
2. Health and safety. Before practice, I will tell an instructor about any health or dental condition, allergy, medication, pregnancy, recent procedure, or other concern that may affect safe participation. I will follow all safety and infection-control directions. I may ask questions or stop a procedure at any time. I understand that stopping may affect my ability to complete the course.
3. Risks and assumption of risk. I understand that instructor supervision does not remove all risk. Practice can cause discomfort, pain, bleeding, cuts, bruising, swelling, soreness, infection, allergic reaction, damage to teeth or restorations, and temporary or lasting nerve or soft-tissue injury. I voluntarily accept these risks and other risks that are not listed or cannot be predicted.
4. Blood or body-fluid exposure and medical costs — Student initials: ______. I understand that sharp instruments and contact with blood or body fluids can expose a person to HIV, hepatitis B, hepatitis C, or other bloodborne infections. If I am cut, punctured, or exposed—or if my blood or body fluid exposes another person—I will stop, report the incident immediately, follow first-aid directions, and cooperate with PLS’s exposure-response procedure attached as Appendix A, which I have received and reviewed. The exposed student must obtain prompt medical evaluation. The student whose blood or body fluid was the source of the exposure must promptly obtain medically recommended testing, subject to rights provided by law. Each student is responsible for all costs related to that student’s initial evaluation, laboratory testing, medications, treatment, and follow-up care. PLS does not provide or pay these costs.
5. Release of liability. To the fullest extent allowed by Florida law, I release and agree not to sue PLS, its owners, officers, employees, independent contractors, instructors, clinical supervisors, agents, host facilities, and participating students (together, the “Released Parties”) for any injury, loss, claim, or damage arising from the course or hands-on practice, including a claim caused by the ordinary negligence of a Released Party. This release does not apply to conduct that the law does not allow to be released.
6. My responsibility and emergency care. I am responsible for claims or losses caused by my intentional conduct or my knowing failure to follow safety instructions. I authorize PLS to contact emergency services if reasonably necessary. I understand that PLS is not responsible for arranging or paying for medical care.
7. Training records. Practice information is used only for training and is not kept as a clinical record. PLS may keep this signed form and any incident report.
8. IMAGE, VIDEO, AND VOICE AUTHORIZATION — INITIAL ONE:
 _____ YES I authorize PLS and those acting for it to photograph or record my image, voice, and participation and to use the material, without payment, for education, training, websites, social media, advertising, promotion, and legal purposes. PLS may edit or crop the material. PLS will not use my full name without separate permission.
 _____ NO I do not authorize PLS to use identifiable images, recordings, or my voice for these purposes.
9. Acknowledgment. I am at least 18 years old. I have read and understand this form. I had the opportunity to ask questions. I sign voluntarily. Florida law applies. If any part is not enforceable, the rest remains effective. I intend this agreement to bind my estate and personal representatives.
 
____________________________         __________              ____________________________                       ___________
Student signature                                        Date                    PLS representative / witness                             Date

This procedure applies to any needlestick, cut with a contaminated instrument, or exposure of the eyes, mouth, nose, or broken skin to blood or other potentially infectious body fluid during hands-on training.
If an Exposure Occurs

  1. STOP IMMEDIATELY AND PROVIDE FIRST AID
    • Needlestick or cut: Wash the area promptly with soap and water.
    • Splash to eyes: Flush the eyes with clean water or saline.
    • Splash to nose or mouth: Flush thoroughly with water.
    • Notify the supervising instructor immediately.
  2. REPORT THE EXPOSURE
    The instructor will immediately notify the Professional Learning Services (PLS) staff member responsible for exposure management and documenting the circumstances of the incident.
    PLS Exposure Contact: Name: Joyce Turcotte – cell phone: 203-218-8233, email: jturcotte@pls.org
  3. OBTAIN PROMPT MEDICAL EVALUATION
    The exposed student must promptly go to the designated medical facility for evaluation.
    The source student, the student whose blood or body fluid was involved—must cooperate with the exposure procedure and promptly report to the designated facility for medically recommended testing, subject to rights provided by law.
    The treating healthcare professional will determine appropriate testing and treatment for HIV, hepatitis B, hepatitis C, and other bloodborne infections based on the type of exposure.
    DESIGNATED POST-EXPOSURE MEDICAL FACILITY
    Facility Name: _Provided day of the course_
    Address: ________________________________
    Phone: __________________________________
    Hours: __________________________________
    If the designated facility is closed or cannot provide prompt post-exposure evaluation, the exposed student should go to the nearest hospital emergency department. Call 911 about a medical emergency.
  4. INFORMATION TO PROVIDE THE MEDICAL FACILITY
    The instructor or PLS representative should provide, when available:
    • Date, time, and type of exposure.
    • Type of instrument involved and how the exposure occurred.
    • Identity the exposed student and source student.
    • Information about the exposed student’s hepatitis B vaccination/immunity status, if available.
    • A copy of this procedure.
    The medical provider, not PLS, will determine the appropriate laboratory testing, medications, PEP, vaccination, or follow-up care.
  5. FOLLOW-UP RESPONSIBILITY AND CONFIDENTIALITY
    Both students must follow the medical provider’s instructions regarding testing, medication, and follow-up care. Test results and medical information are confidential and will be handled and disclosed only as permitted by law. PLS will maintain an incident report but does not maintain the students’ medical test results.
  6. MEDICAL COSTS
    As stated in the Student Waiver Form, each student is responsible for all costs related to that student’s initial medical evaluation, laboratory testing, medications, treatment, and follow-up care. PLS does not provide or pay these costs.

    Important: A blood or body-fluid exposure must be reported immediately even if the injury appears minor or the source student believes that they do not have a bloodborne infection.