Basic Information

Exposure Waiver

I understand there is potential risk for exposure to bloodborne pathogens (BBP’s) including Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at Wake Smiles Dental Clinic.

I understand that I am personally responsible for any medical fees and services associated with percutaneous piercing wound, typically set by a needle point, but possibly by other sharp instruments or objects.

I understand that this is a donation of my services and that I am responsible for my own medical care. I also understand that I am not entitled to reimbursement from Raleigh-Wake County Dental Society Community Dental Health Program, INC. (Wake Smiles) for any of my expenditures.

HIPAA Privacy and Confidentiality Statement

I understand that as a volunteer at Raleigh-Wake County Dental Society Community Dental Health Program, INC. (Wake Smiles), I will see, hear and/or otherwise have access to confidential health information and patient records.

Confidential information may include personal patient information, radiographic images and treatment plans. This should:

  1. Only be accessed by employees or contracted personnel when needed to perform dental procedures.
  2. Be protected at all times.
  3. Remain confidential even upon completing the volunteer experience.

I hereby certify that I have read this document and am aware of the confidentiality requirements expected of me. I pledge to not disclose any confidential information learned at Wake Smiles.