Lynn's Dental Hygiene Services 2/23/2017

EXHIBIT A SCOPE OF WORK DENTAL HYGIENE SERVICES *In consideration for the dental hygiene services provided by Service Provider,the City will provide a space in the Carl Gipson Senior Center of Everett(the"Senior Center")for Service Provider to perform the dental hygiene services under this Agreement.Pursuant to the terms of the Agreement, Service Provider will: *Obtain from the patient or responsible party,written consent for any work provided by SErvice Provider to the Patient. *Obtain from the patient's primary care physician patient medical information that is releveant to the provision of preventative dental care before providing services to the patient. Collect data on the patients,including age,treatments rendered,insurance coverage,if any,and patient refreeal to dentists,the reason for the referral any other information in accordance with federal,state and local laws and regulations. *Supply instruments, supplies and portable equipment used to provide dental hygiene services. *Perform comprehensive dental hygiene evaluations. *Perform limited visual oral assessments. *Perform routine therapeutic dental cleanings. *Perform fluoride applications. *Perfonn denture/partial cleaning *Provide educational classes. *Offer financial and referral consultations. *At all times comply with RCW 18.29.056,related to the provision of dental hygiene services provided in senior centers. FEES *Fees for the dental hygiene services provided at the Senior Center will be paid directly by participants to Service Provider,and are the sole responsibility of the Service Provider. BACKGROUND CHECK *Service Provider agrees to submit to a Washington State Patrol Criminal Background Check to determine if Service Provider has prior convictions that would disqualify Service Provider from working with children or vulnerable adults. If such a record exists,this Agreement will be terminated immediately. CLEANING *Service Provider will: *Clean and straighten up assigned work spaces after each use. *Return furniture to its original position. Page 12 (Form Approved by City Attorney's Office January 7,2010,updated June 15,2014)