REQUEST FOR DENTAL CARE
❖ I hereby request to participate in and receive assistance that will be provided to me free of any cost or expense to me by D-DENT volunteers.
❖ This request is entirely voluntary on my part and is made with knowledge of the volunteer immunity described above, and with the understanding that in providing such assistance there are inherent risks of unintended accidental and/or negligent damages or bodily injury to me.
❖ In exchange for receiving free services through D-DENT, I understand and accept that applicable laws may deny me the right to recover any monetary damages from D-DENT or any volunteer working through D-DENT, as a result of services provided by volunteers.
❖ I hereby authorize D-DENT through its staff and volunteers to provide the requested care.
❖ I hereby authorize D-DENT volunteer dentists, hygienists, dental assistants, to perform dental care on me and to perform any first aid or emergency medical care that may become reasonably necessary for me in the course of such treatment.
❖ This request for assistance from D-DENT may be considered by D-DENT and its volunteers to be a continuing authorization, and shall remain effective as evidence of my consent for D-DENT volunteers to provide the care I requested until I specifically notify D-DENT in writing that I am revoking and withdrawing my prior request, authorization, or consent.
NOTICE OF LEGAL IMMUNITY FOR VOLUNTEERS
• ALL OF THE PERSONS THAT PROVIDE CARE AND SERVICES FOR D-DENT PARTICIPANTS ARE VOLUNTEERS.
• VOLUNTEE VOLUNTEERS PROVIDING FREE SERVICES HAVE LEGAL IMMUNITY FROM LIABILITY IN CIVIL ACTIONS UNDER STATE AND FEDERAL LAWS FOR THE VOLUNTEER SERVICES, INCLUDING HEALTH CARE.
• IF A COURT DECIDED THAT A VOLUNTEER IS ENTITLED TO THE PROTECTION UNDER THESE LAWS, YOU WOULD NOT BE ABLE TO RECOVER ANY MONEY FOR ANY DAMAGE OR BODILY INJURY, EVEN IF YOU FILE A LAWSUIT.
PATIENT RESPONSIBILITIES GUIDELINES
1. Get my own ride to each dental appointment.
2. Arrive on time or early (15 minutes before scheduled time)
3. Be kind, thankful, respectful and cooperative at all times with D-DENT staff, as well as the volunteer dentists and their staff.
4. I understand and agree that if at any time during my waiting period or during my treatment, I behave inappropriately, discourteous or uncooperative, act or talk rude to D-DENT staff and/or volunteer dentists and their staff, I will be disqualified to receive dental care. This means that I will be removed from the D-DENT program and I will not be eligible to receive and/or continue dental treatment through D-DENT.
5. I understand that ONE (1) NO SHOW appointment MAY disqualify me from receiving dental care through D-DENT.
6. I understand and agree that all appointments must be made by D-DENT staff and that I am responsible for calling D-DENT after each dental appointment to report appointment information.
7. I agree to NOT cancel or change any dental appointments unless I have called and received permission from D-DENT staff.
8. I understand that D-DENT is a one-time pass through program. After the volunteer dental professionals have finished their treatment, my case
will be considered COMPLETED and I will not be eligible for future dental treatment through D-DENT.
9. I understand and agree to follow directions of the dentists and staff to preserve and do my best to maintain my dental health, including the practice of regular dental hygiene procedures and care of prosthetic appliances as indicated.
10. I understand and agree that I can be dropped from the D-DENT program at any time if I do not follow the rules of this contract.
11. I understand that if I'm eligible, I will be placed on a WAITING LIST. The waiting period varies per case. It can be anywhere between one (1) month to five (SJ years depending on the need, the area of residency, volunteers, and funding availability.
BY SIGNING THIS FORM YOU AGREE TO THE FOLLOWING STATEMENTS:
✓ I have read and understand the 11 PATIENT RESPONSIBILITY GUIDELINES listed above.
✓ I have read and understand the NOTICE OF LEGAL IMMUNITY FOR VOLUNTEERS listed above.
✓ I have read and understand the REQUEST FOR DENTAL CARE that I am making as listed above.
✓ I understand that I can request a copy of D-DENT's notice of privacy practices (HIPAA) by calling 405-424-8092.
✓ I certify that I understand the questions on this form and the penalties for giving false statements or withholding information.
✓ Under the penalty of perjury, I certify that I have given true, accurate, and complete statements to the best of my knowledge, for each household member, including myself, for whom I am applying.
✓ I authorize D-DENT to share information about my application, dental needs and dental treatment with FUNDING SOURCES & D-DENT'S VOLUNTEER DENTISTS as well as those listed as contacts on this form.
✓ I authorize D-DENT to request information about my dental treatment, including x-rays, treatment plan, and treatment notes from volunteer's dental clinic.
IF YOU HAVE QUESTIONS ABOUT ANY OF THE STATEMENTS ABOVE, CALL D-DENT AT (405) 424-8092 AND ASK THE STAFF TO PROVIDE FURTHER EXPLANATION, BEFORE YOU SIGN THIS REQUEST FOR ASSISTANCE.