Detroit Mercy Dental TFTMC Consent Form Logo
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  • School Based Dental Services Program

    Dental Consent and Medical History
    • Dental exam
    • X-rays
    • Teeth cleaning
    • Fluoride treatment
    • Sealants (on adult molars)
    • Fillings
    • Extractions (baby teeth)
    • Pulpotomy (removing tooth nerve)
    • Stainless steel crowns (caps)
    • Dental referrals (as needed) 

  • Dear parent or guardian: The University of Detroit Mercy School of Dentistry’s Titan’s for Teeth Mobile Programs (TFTMP) is pleased to provide dental care at your child’s school during school hours. Dental treatment will be provided only as needed.

    The treatment will be carried out by dental students under supervision of a licensed dentist and/or dental hygienist faculty. Nitrous Oxide (happy air) and/or local anesthetic (tooth numbing medicine) may be used for some procedures. If you would like for your child to receive services please complete this form and return to the School. If your child does not have dental insurance or if you have any questions about the program, please contact our Mobile Program Coordinator at (313) 355-0390.

  • FORM MUST BE FILLED OUT COMPLETELY IN ORDER FOR YOUR CHILD TO RECEIVE SERVICES.

  • CHILD’S INFORMATION

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  • FORM MUST BE FILLED OUT COMPLETELY IN ORDER FOR YOUR CHILD TO RECEIVE SERVICES.

  • CHILD'S INSURANCE INFORMATION

  • For children with private insurance, Parent/guardian is responsible for deductibles and co-pays.

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  • FORM MUST BE FILLED OUT COMPLETELY IN ORDER FOR YOUR CHILD TO RECEIVE SERVICES.

  • CHILD'S MEDICAL HISTORY

    Please be as through as possible.
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  • FORM MUST BE FILLED OUT COMPLETELY IN ORDER FOR YOUR CHILD TO RECEIVE SERVICES.

  • Consent for Dental Treatment

    Electronic Signature Consent

  • 1. I am the legal guardian of the child. I have read and understand the information on this form. This form is to obtain my consent for dental treatment for my child. By signing this electrnic consent form, I give permission for my child to receive dental treatment from the University of Detroit Mercy School of Dentistry's Titan For Teeth Mobile Clinic (TFTMC).

    2. I understand that these services can be obtained at the office of my child’s dentist rather than at the TFTMC and may affect benefits that my child receives from private insurance, a state or federal program, or other third-party provider of dental benefits.

    3. I have answered every question above completely and accurately. I will inform the TFTMC of any change in my child’s health and/or medications. 

    4. I understand that the TFTMC will bill my child’s private insurance or Medicaid if available and that I will be required to provide my insurance information to receive the services.

     **If your child does not have dental insurance, please contact the Program Manager
    at     313-355-0390 for additional options**

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