(a) That by signing this form, patient is consenting to receive an oral health assessment (dental screening) and included is fluoride application.
(b) This screening is only a very basic evaluation and does not take the place of a thorough dental examination, and that establishing and maintaining patient’s health requires securing the services of a dentist to perform a complete dental examination.
(c) That receiving this dental screening does not establish any new or ongoing doctor-patient relationship, and that patient is free to establish such a relationship with the dentist performing this screening or with another dentist of his/her choice.
(d) Patient will not hold the dentist or those performing this assessment, Vital Smiles or their affiliates responsible for the oral health consequences or results should patient choose NOT to follow the recommendations listed below.
