HEALTHY ATHLETE DENTAL CARE CONSENT AND WAIVER FORM

I understand that by signing below I consent to participate in the Special Olympics New Jersey (SONJ) Healthy Athletes program that provides individual screening assessments of health status and health care needs in the area of oral health. I understand there is no obligation for me to participate in the Healthy Athletes Program should I decide not to participate. Provision of these health services is not intended as a substitute for regular care. I also understand that I should seek my own independent medical advice and assistance irrespective of these services and that SONJ is not responsible for my health. I understand that information that is gathered as part of the screening process may be used in group form (anonymously) to assess and communicate the overall health needs of athletes and to develop programs to address those needs.

At this event, dental health care professionals to provide additional dental care. The dental care provided may consist of invasive treatment including extractions and fillings, should the provider deem them necessary and in the event you provide your permission. By signing below you agree to waive and release SONJ, and any other organization or company or persons acting on SONJ behalf or sponsoring or volunteering at the Healthy Athletes program screening and clinic, from all claims of liability arising out of the free care received by you, including but not limited to, medical, surgical and/or dental care or provision of other health care or medical advice.

1. X-Rays & Examination: I understand that that I will be receiving a dental examination from a state licensed dental practitioner. I understand that while X-rays are taken of my teeth, I will be exposed to a minimal amount of radiation as part of the necessary requirements to complete a thorough and comprehensive examination. I also understand that if I am pregnant radiation exposure poses a serious threat to the life and health of my unborn child. Pregnant women are required to have a medical release from their Medical Doctor prior to X-rays and Dental treatment.

2. Changes in Treatment Plan: I understand that during treatment it may be necessary to change procedures or add procedures because of conditions discovered while working on the teeth that were not found during examination. I understand there may be unforeseen changes that can occur during treatment. I understand that whenever possible, I will be informed of any treatment changes in advance. I give my permission to the Dentist to make any and/or all changes and additions as necessary.

3. Drugs and Medication: I understand that antibiotics, analgesics and other medications can cause allergic reactions. The reactions can include redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock.

4. Removal of Teeth: Alternatives for tooth removal have been explained to me (root canal therapy, crowns, and periodontal surgery) and I understand that during treatment it may be necessary to authorize the Dentist to remove teeth for reasons outlined in paragraph #2. I understand that removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the following risks associated with having teeth removed: pain, spread of infection, dry socket, swelling, fractured jaw, loss of feeling in my teeth, lips, tongue and surrounding tissue that can last for an indefinite period of time. I understand I may need further treatment by a specialist, the cost of which is my responsibility.

5. Periodontal Loss: I understand I have a condition which causes gum and bone inflammation and/or loss, and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedure may have future adverse effect on my periodontal condition.

6. Fillings: I understand that care must be exercised in chewing with fillings, especially during the first 24 hours, to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after- effect of a newly placed filling. If the sensitivity continues, I understand that a root canal may be needed, even though the tooth may not have hurt prior to the filling being placed.

7. Silver Diamine Fluoride: Silver Diamine Fluoride is a medication that is applied to an active area of decay (cavity) to kill the bacteria causing the infection, prevent the formation of a plaque biofilm layer on the treated surface, restrengthen the tooth and help prevent cavities in other teeth. It is important that you are made aware that treating cavities with this medicine will cause color changes to the infection (cavity). The areas of the tooth with active dental decay will turn black as the medicine is working and the infection is stopped. The healthy areas of the tooth will remain the natural tooth color. The black color indicates that the treatment is working. (Reapplication of Silver Diamine Fluoride is recommended every 3-6 months and thereafter until the tooth is restored.) It is also important that you are aware that while this medicine will stop the infection, it will not restore the tooth structure that has already been lost by the disease process. You or your child may still require restoration of the tooth (fillings, crowns and possibly nerve treatment) if there is any loss of tooth structure. Our team will discuss the recommended timing of this treatment, and will discuss the best way to provide this treatment to ensure that you or your child receives treatment in the least invasive, most predictable and least traumatic way possible.

MAILING ADDRESS FOR PRESCRIPTION EYEWEAR

If you are attending Opening Eyes, you will not receive your prescription eyewear day of the event. Instead you need to provide your correct mailing address below and confirm at the end of the screening during check out so that way SONJ can mail your eyewear to the correct address.