Informed Consent for General or Remote Supervision

I understand that the records for services provided by the dental hygienist will be reviewed by a Virginia licensed dentist providing the hygienist general supervision. I understand that treatment I receive from the dental hygienist is limited in scope and that it does not take the place of a regular dental examination or treatment by a licensed dentist. I understand that the dental hygienist may refer the patient to a dentist or other specialist for further treatment when a dental condition requires more treatment that the dental hygienist can provide.

Agreement Between Dentist and Hygienist:

(1) The dental hygienist will practice according to the parameters set forth in this agreement.

(2) The dentist providing general supervision must be available for consultation but is not required to be physically present at the site where dental hygiene services are provided.

(3) The dental hygienist working under this agreement and supervising dentist agree to maintain communication and consultation with each other.

(4) The hygienist will provide the dentist opportunities to review patient records as requested.

(5) The dentist will review the records of patients treated by the dental hygienist from the beginning of general/remote supervision. Reviews will include records of all patients seen. Reviews must occur no less than once every 10 (ten) months at a minimum. The dentist may determine the need for and conduct more frequent reviews. Subsequent reviews of records need only encompass patients seen since the last review.

(6) Limitation on treatment: (a)When the patient’s dental condition requires services beyond what the hygienist can provide, the hygienist will advise or refer the patient to obtain dental or other care.

(b) For patients who have been treated by a hygienist under general/remote supervision and since treatment began have not been seen or examined by a dentist in the last 10 months, the hygienist should inform the patient or guardian that an examination by a dentist is strongly recommended if not required in some cases.

If a school or institution obtains consent for dental hygiene services provided at its facilities, the dental hygienist shall make and document reasonable efforts to ensure that the consent form used by the school or institution provides an equivalent notice and that patients, parents or guardians are aware of the information in the consent form above.