Continuing Dental Education School of Dentistry, CB #7450 University of North Carolina Chapel Hill, NC 27599-7450 (919) 537-3400 Fax (919) 537-3098 Email: CDE@dentistry.unc.edu MEMORANDUM To: Participants in Coronal Tooth Polishing for Dental Assistant IIs Required Forms: Consent Form and Patient Bill of Rights Employment and Professional Liability Insurance Coverage Dental and Medical History Forms DA II Status Verification Form Bring to course: Safety glasses and scrubs. Note: Do you need to premedicate? If so, we need to know. Requirements: Course participants must be working as a Dental Assistant II and be at least 18 years of age. Coronal Tooth Polishing for Dental Assistant IIs will be held Friday, August 14, 2015 at the UNC School of Dentistry Koury Oral Health Sciences Building, located at the corner of Manning Drive and South Columbia St, Chapel Hill, NC. Registration begins at 8:00am and the activity will start at 8:30am. The attached forms must be completed and returned to the CDE office by Wednesday, August 5, 2015. • The Consent Form states that you agree to be both a patient and a participant in this continuing education activity. • The Employment and Professional Liability Insurance Coverage form states that you are employed in a professional practice and that you have insurance coverage. This form will also need the signature of your dentist/employer. • The Medical and Dental History Forms will provide UNC School of Dentistry with your dental healthcare history. Course faculty will review your medical history prior to the clinical portion of this course. • The verification of DAII status form states that you are eligible for Dental Assistant II status according to the Dental Laws of NC. This form will also need the signature of your dentist/employer. • You may return these forms by mail or fax them to the CDE Office at 919-537-3098. The University of North Carolina School of Dentistry cautions continuing dental education participants that there are potential risks of using limited knowledge when incorporating new techniques and procedures into the practice of dentistry, especially when the continuing education course has not provided supervised clinical experience and/or competency tests in the techniques or procedures.