Dear Applicant:

Thank you for your interest in our Local Anestltesia for Dental Hygienists course. This course meets standards established by the Florida Board of Dentistry and is designed for qental hygienists to receive a certificate for 60 hours of training.

At the conclusion of instruction, participants will be able to demonstrate and/or describe the following as specified by F.S. 466.017 concerning anesthesia:

1. Theory of pain control. 2. Selection-of-pain-control modalities. 3. Anatomy. 4. Neurophysiology. 5. Pharmacology of local anesthetics. 6. Pharmacology of vasoconstrictors. 7. Psychological aspects of pain control. 8. Systemic complications. 9. Techniques of maxillary anesthesia. 10. Techniques of mandibular anesthesia.

11. Infection Control. 12. Medical emergencies involving local anesthesia.

Format of course:

• 15 hours didactic (on campus) • 15 hours online (a portion must be completed prior to the first day of lab)

• 15 hours lab (on campus) • 15 hours clinicaLexternship (must be completed within 30 business days of the final date of course)

• Florida CE Broker reporting and certificate will be issued upon successful completion of course .

Students are required to supply:

D Protective safety glasses/goggles

D Clinical attire/scrubs

D Textbook: Logothetis, Demetra, D., Local Anestltesiafor tlte Dental Hygienist 2"d Edition, Elsevier­Mosby, 2017, ISBN# 978-0323-3963-32

Please see the attached checklist to ensure proper documentation is submitted prior to registration.

APPLICANT CHECKLIST

Course Applicant:---------------------------­(Print name, phone number & email address)

Please check off the items below to verify all prerequisites are met. Provide a copy of the required documents and proof of vaccinations, name included, to GCSC Healthcare CE Coordinator prior to registration.

[] Florida Dental Hygiene license (current)

[] CPR card in accordance with Florida Board of Dentistry mandates (must be a live course)

[] Hepatitis B Vaccine or titer results

[] TB (PPD) skin test results (current-within a year)

[] MMR vaccine

[] Tetanus-Diphtheria vaccine

[] Polio vaccine

[] Varicella (Chickenpox) vaccine or documented exposure or titer results

[] HIP AA (training certificate dated within past 2 years & include a FL approved provider number)

[] Prevention of Medical Errors (training certificate dated within past 2 years & include a FL

approved provider number)

[] Signed Confidentiality Statement

[] Signed Informed Consent and Release Statement

[] Signed Clinical Externship Agreement signed by supervising dentist

Contact your local health department if you have questions concerning your vaccinations. It is the responsibility of the course participant to provide the above documents.

Deliver in person, fax or email your documents with this checklist to:

Sherrie Lock, CE Coordinator Corporate College Division of GCSC Student Union East Building, Room 210 5230 West U.S. Hwy. 98, Panama City, FL 32401 Email: slock@gulfcoast.edu I Phone: 850-872-3819 I Fax: 850-747-3258

Received by:---------------- Date received: ________

CONFIDENTIALITY STATEMENT

Name (printed)

understand that I am solely responsible for compliance with the policies of Gulf Coast State College (reference GCSC handbook), rules of the provider offering the clinical externship, and all federal and state IBP AA Privacy and Security Laws.

I understand that violation of this agreement will result in immediate dismissal from the course and potential civil or criminal penalties.

Signature Date

LOCAL ANESTHESIA FOR DENTAL HYGIENISTS

INFORMED CONSENT AND RELEASE AGREEMENT Acknowledgment of Receipt of Inform;

As a consenting adult, I agree to permit fellow students and faculty of Gulf Coast State College Dental Programs to perform anesthesia procedures as applicable to the Local Anesthesia f or Dental Hygienists course in which I am enrolled. Please realize that what you are being asked to sign is a confirmation that we have discussed the nature and purpose of the procedure(s), the known risks associated with the procedure(s), and the feasible alternatives; that you have been given an opportunity to ask questions and that all your questions have been answered to your satisfaction. Please read this form carefully before signing it and ask about anything that you do not understand. You are advised that the primary purpose of the Local Anesthesia for Dental Hygienists course is for teaching purposes and therefore you will be participating in the teaching program. We will be pleased to explain anything further to you.

Consent and Release

Before receiving any injection, I acknowledge that I have asked or had the opportunity to ask the dental faculty about the injection procedure(s) and having asked such questions consent to the commencement of the procedure(s). I hereby authorize and direct the Dental Student to assist and/or provide practice of local anesthesia procedures as evaluated by a licensed dentist and/or dental hygiene faculty member.

Procedures practiced may include, but are not limited to: Medical and Dental History analysis and continuous review and the application of topical/local anesthesia as administered by the student, licensed Dental Hygienist, and/or licensed Dentist. While highly unlikely, we must inform you that there may be irritation of, or damage to, the tissues involved, including that caused by any injected anesthetic medications.

Authorization to Utilize Images

I also authorize Gulf Coast State College to use and/or permit others to use the aforementioned images in the following educational, informational and promotional activities without compensation. Initial each authorized activity.

News Media Educational Publications/Videos __ Institutional Promotion/Advertising __ Electronic Publishing (i .e. World Wide Web)

Liability and Release

The undersigned acknowledges that the College is a public institution that is subject to the Florida Sunshine Laws that require the records and documents of the College to be available for public inspection. The undersigned acknowledges that his/her records may be subject to the Florida Sunshine Laws and therefore possible distribution to the public in the event of a public records request. The College will maintain any documents such as medical or dental records that is privileged and protected by other federal or state Jaws.

By signing this form, I am consenting to the procedure(s) associated with the.Local Anesthesia for Dental Hygienists course and I am releasing Gulf Coast State College from liability from any injury that might occur as a direct result from this/these procedure(s). Before participating in scheduled lab sessions, I acknowledge that I have read and that I understand this consent agreement, that I have been given an opportunity to ask any questions I might have had, and that those questions have been answered in a satisfactory manner. I also understand that I am free to withdraw my consent to receive an injection at any time.

Signature of Student

Signature of GCSC Local Anesthesia Course Representative

Date and Time

(Business le!lerhead)

CLINICAL EXTERNSHIP AGREEMENT LOCAL ANESTHESIA FOR DENTAL HYGIENISTS

Name ofDental Hygienist (printed) License Number

has obtained permission to obtain 15 hours of clinical externship in this office/facility as required by the Local Anesthesia for Dental Hygienists course in which he/she is enrolled. All observations/participation will be documented by the supervising licensed Dentist. I understand that provision for this externship must be provided and completed within thirty (30) business days of the final date in the course series.

Signature ofSupervising Dentist License Number Date

-------------------THIS SECTION TO BE COMPLETED AND RETURNED TO:-------------·-­

Gulf Coast State College ATTN: Sherrie Lock, Healthcare CE

Student Union East Room 210 5230 West U.S. Hwy. 98, Panama City, FL 32401

slock@gulfcoast.edu - email (850) 872-3819 - phone I (850) 747-3258 - fax

Date (ddlmm/yy)

Time (hours/minutes)

Type of injection(s) observed/ demonstrated

Date (ddlmmlyy)

Time (hours/minutes)

Type of injection(s) observed/demonstrated

TOTAL TIME: ___ Signature ofSupervising Dentist Date ofCompletion