Statement of Patient’s Responsibilities

As a patient in the Halifax Community College Dental Clinic,you have responsibilities as well as rights. You have theresponsibility to:

1. Share honestly and completely your medical and dentalhistory, previous illnesses, hospitalizations, exposure to com-municable diseases, information about medications and al-lergies and your current medical care.

2. Follow treatment recommendations and ask questionsabout anything you do not understand.

3. Keep scheduled appointments and give at least 48 houradvance notice if unable to keep your scheduled appoint-ment.

4. Be prompt for your appointments. It is important thatstudents have adequate time to deliver complete care.

5. Be an active participant in the dental care of yourselfand your family. Ask questions to clarify the nature of yourdental health and treatment provided.

6. Contact your personal dentist for regular dental care anddental hygiene care if you are not selected as a patient orhave not been contacted by the time your regular checkup isdue. The Dental Clinic cannot guarantee regular, periodiccleaning appointments for anyone.

Fees

.................................................................$ 10.00................................................................... 20.00

(6-month recall)

............................................................. 15.00......................................... 10.00

............................................................ 15.00(3-month recall)

................................................................................ 5.00(per tooth)

............................................................ 10.00.................................................................... 5.00................................................................. 10.00................................................................. 10.00

Dental ClinicPatient Information

Halifax Community CollegeP.O. Drawer 809

Weldon, NC 27890(252) 536-7219

Statement of Patient’s Rights

As a patient in the Halifax Community College DentalClinic you have the right, consistent with law to:

1. Receive treatment without discrimination as to race,color, religion, sex, national origin, disability or sexualorientation.

2. Request accommodation for a disability by complet-ing the “Request for Accommodation” form in advance,so as to provide the college sufficient and adequate timeto meet your needs. You may obtain this form from theAdmissions Office.

3. Receive considerate and respectful care in a cleanand safe environment free of unnecessary restraints.

4. Know the names, positions, and functions of anydental instructors, staff, and students in the Dental Clinicwho are involved in your care.

5. Refuse treatment, examination, or observation byany instructor or student before or after being informedwhat effect this may have on your health.

6. Receive complete information about your furthertreatment needs and any referral that is advised.

7. Receive all the information that you need to giveinformed consent for any proposed procedure of treat-ment. This information shall include the possible risksand benefits of the procedure or treatment as well as thecost.

8. Have confidentiality of all information and recordsregarding your care.

9. Review your record and obtain a copy of your recordupon written request.

10. Receive dental hygiene treatment that meets thestandard of care.

11. Share concerns about the care and service you re-ceive without fear of reprisals, and have the clinic super-visor respond to you. All concerns should be directed tothe Dental Clinic Supervisor.

Child CleaningAdult Cleaning

Scaling/Root Planing First Quadrant Each Additional QuadrantPerio Maintenance

Sealants

Full Series X-RaysBitewing 2-FilmBitewing 4-FilmPanoramic Film

STATEMENT OF PATIENT’S RESPONSIBILITIESAs a patient in the Halifax Community College Dental Hygiene

Clinic, you have responsibilities as well as rights.

You have the responsibility to:

1. Share honestly and completely your medical and dental history, previous illnesses, hospitalizations, exposure to communicable diseases, information about medications and allergies and your current medical care.

2. Follow treatment recommendations and ask questions about anything you do not understand.

3. Keep scheduled appointments and give at least 24 hour advance notice if unable to keep your scheduled appointment.

4. Be prompt for your appointments. It is important that students have adequate time to deliver complete care.

5. Be responsible for following the recommended instructions given by the student and dental hygiene clinic faculty including follow-up treatment instructions and recommendations

6. Contact your personal dentist for regular dental care and dental hygiene care if you cannot be scheduled in the HCC Dental Hygiene Clinic. The HCC Dental Hygiene Clinic cannot guarantee regular, periodic dental hygiene appointments for anyone.

DENTAL HYGIENE CLINIC RULES

• All cell phones must be turned off in the clinical area.• No audio, video, or photographic recording of students, faculty, or staff is permitted.• Only the patient is allowed in the clinic treatment area.• Parents or guardians of minors are permitted in the clinic area to review health history, review oral health care instructions, and sign treatment consent. • Children are not allowed in the clinic area when their parent or guardian is the patient.• Infants or small children are not allowed to remain in the reception area unattended.

STATEMENT OF PATIENT’S RIGHTSAs a patient in the Halifax Community College Dental Hygiene

Clinic you have the right, consistent with law to:

1. Receive treatment without discrimination as to race, color, religion, sex, national origin, disability or sexual orientation.

2. Expect confidentiality with regards to personal information, medical information, dental information and dental services needed.

3. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.

4. Have the right to receive treatment on a reasonable schedule based on the students’s skill level and the clinic’s schedule

5. Decline any treatment offered; however you will be advised of the risk involved in declining treatment

6. Receive complete information about your further treatment needs and any referral that is advised.

7. Receive all the information that you need to give informed consent for any proposed procedure of treatment. This information shall include the possible risks and benefits of the procedure or treatment as well as the cost.

8. Review your record and obtain a copy of your record upon written request.

9. Receive dental hygiene treatment that meets the standard of care.

10. Share concerns about the care and service you receive without fear of reprisals.

Prophylaxis*Includes one or all of the following: fine scale, polish, exam

Child Cleaning $10.00Adult Cleaning (6 months recall appointment) $20.00

Scaling/Root Planing (1st quadrant) . . . . . .Each additional Quadrant . . . . . . . . . . . . . . . .

$15.00$10.00

*Periodontal Maintenance (3 months recall appointment) $15.00

Gross Debridement $20.00

Sealants (per tooth, $40.00 max) $5.00

X-Rays

Full Mouth Series X-Rays $10.00Bitewing X-rays $ 10.00Panorex $ 10.00

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Dental Hygiene Clinic

Halifax Community College100 College DriveP.O. Drawer 809

Weldon, NC 27890252.536.7219

CLEANING APPOINTMENTEach clinic session is 3 hours long, and patient treatment time is 2 ½ hours. Usually, more than one appointment is required to complete treatment. If you do not have time to allow the student to complete your cleaning, please do not begin treatment. Students receive credit only for completed patient assignments. If time is a problem, we suggest that you seek treatment in a private dental office. The fee for treatment at HCC Clinic will depend on the patients’ needs and the student’s assignment.

CANCELLATIONSIt is very important that you arrive promptly for each appointment. Our students must complete a certain number of patients each semester. Your failure to keep an appointment could result in a student not graduating. All cancellations and no-show appointments will be recorded in your chart. Any patient who fails to keep two appointments, without adequate notice, will not be scheduled for further care in our clinic. You are expected to give a minimum of 24 hours notice if you must reschedule an appointment.

DIRECTIONS TO CAMPUSFrom North or South of Roanoke Rapids take I-95 tothe Roanoke Rapids-Weldon US158 Exit #173.

Go East on 158. From East or West take US 158 toWeldon.

The campus is about a mile east of Interstate 95 onUS 158. The dental clinic is in the Allied HealthBuilding.

Dear Patients:Welcome to our clinic. We hope you will take a few minutes to read this information pamphlet. This information should answer many of the questions you have about our clinic.

Please remember, this is a teaching institution. Our major goal is to offer the best education to ourstudents while providing the highest quality care for patients. Due to added paperwork and the process of checking our students’ performance, your appointment will take longer than in a private dental office. It may also be necessary for you to return for additional appointments in order to complete your treatment. We appreciate your patience and cooperation. Our students and faculty are here to provide dental hygiene care only. We do not diagnose or treat dental disease. Any additional care you may require, should be secured through a private practice office. We strongly urge you to maintain a regular schedule for checkups with your dentist.

We sincerely hope that your experience in our clinic will be beneficial. If we can assist you in any way,please let us know.

Sincerely,

Dental Hygiene Faculty & Staff

X-RAYIf it is determined that you need x-rays, the student will advise you of the need for x-rays, obtain your consent, and advise you of the fee. All patient x-rays are digital, and hard copies of the x-rays can be given to the patient. EagleSoft digital software is used for the digital x-rays in the HCC Dental Hygiene Clinic.