Smile Check Consent

Delaware Smile Check Program
Are you interested in an on-site or virtual screening?*

On-siteVirtual
On-site:

This option allows participants to receive a face-to-face in-person screening from a licensed Delaware dental hygienist, at school or another participating organization. Those eligible can also receive an application of fluoride varnish, which can prevent up to a third of cavities in baby teeth. All screened get an oral health bag with age appropriate supplies and oral health education. If you don’t have a dentist, Healthy Smiles can help find one.

Virtual:

This option allows children or adults who are Delaware residents to be screened remotely from their location. By answering a series of questions, individuals can get recommendations, resources, and referrals based on their answers and the needs of their family. Care coordinators will help identify the habits that put the person at risk for poor oral health.
Student Information:
Full Name*

First NameLast Name
Gender*

MaleFemale

Parent / Legal Guardian:
Name*

First NameLast Name
Relationship to child*
Email*
example@example.com
May we send you email?*

YesNo
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
What is the best time to contact you? Check all that apply.*

MorningsEveningsWeekdaysWeekends
If we need to contact you about this child's screening results or to help you find a dentist, what is the best way to reach you? Check all that apply.*

CallTextEmail

Emergency Contact Information:
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*

Consent:
By signing this consent, I hereby certify that the above information is true and complete. I consent to a screening and, if necessary, an application of fluoride varnish to help prevent cavities. I understand that if my child has Medicaid, the insurance will be billed for any services received. If my child does not have Medicaid, he/she can still participate at no cost to me. I consent to my child’s Body Mass Index (BMI) being recorded during this screening by use of a scale for weight and a ruler for height. All screening results and BMI data are strictly confidential.
Parent / Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Consent for exams / tests / treatment services, including release of health and insurance information:

Please read the following information carefully.
This consent indicates that you or your child may be examined, have appropriate tests, receive treatments and/or minor procedures, receive referrals, and/or receive any other services by a person authorized by the Division of Public Health (DPH). You have reviewed the DPH policy on chaperones and discussed it with your child.
You certify that you are:*

ClientParentLegally authorized representative
Consent to participate in the Health Information Exchange:

Receipt of Notice of Patient Privacy Practices (Acknowledgement)
By submitting this agreement, you acknowledge the Notice of Patient Privacy Practices.

Health Information Exchange

Delaware’s Health Information Exchange Network (DHIN) allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance, and state law reporting requirements. Understand that if you go to a Delaware Health and Social Services (DHSS) or Division of Public Health (DPH) facility, staff may get a copy of health care information electronically through various health information exchange connections with other health care providers.

By submitting this consent, you agree to the use and release of all health care information for treatment, payment, and health care operations among the affiliated entities of Delaware Health and Social Services, Notice of Patient Privacy Practices, as amended from time to time.
Additional Information to be Excluded:
Assignment of Benefits and Medical Records Release to Delaware Health and Social Services, Division of Public Health:
Submitting this consent gives authorization for the following: Any insurance benefits are to be paid directly to DHSS; the release of pertinent medical information to insurance carriers; the responsibility to pay for non-covered services; to release and hold harmless the State of Delaware, DHSS, DPH, and its agents and/or staff from any liability for any injuries suffered as a result of any exams, test, treatment, and/or services rendered; the consent to taking samples, cultures, or lab tests that are deemed necessary; the chance to correct and change information to make sure it is correct and complete; to know what information is being disclosed.

I have read this form and/or if requested, had it read to me. Any disclosure of my Protected Health Information (PHI) carries with it the potential for disclosure by the recipient, and the PHI may not be protected by the federal privacy rules.

This consent shall apply to all Division of Public Health services for a period of one year from the date of submission and can be revoked, in writing, at any time. Please note, receiving family planning services is not a prerequisite for receiving any other services offered by DPH.
Printed Name of Client / Parent / Representative:*
Signature*

Clear
Date*

MonthDayYear
Date

	Entry
Drink
Snack
Meal

The form is complete and ready to be submitted.
Should be Empty:

	Yes	No	Not sure
Dark or white spots on the teeth
Swollen or red bumps or blisters around gums or in the mouth
Red or bleeding gums
Teeth that are visibly crooked, crowded, or that stick out
An adult tooth coming in behind or under a baby tooth
Swelling in the face
A baby tooth that has an adult tooth coming in behind or under the baby tooth
Chipped teeth

	Yes	No	Not Sure
Dark or white spots on the teeth
Swollen or red bumps in the mouth
Red or bleeding gums after brushing
Swelling in the face

Delaware Smile Check Program

On-site:

Virtual:

Student Information:

Student Information:

Student Health History:

Parent / Legal Guardian:

Emergency Contact Information:

Consent:

Consent for exams / tests / treatment services, including release of health and insurance information:

Consent to participate in the Health Information Exchange:

Health Information Exchange

Assignment of Benefits and Medical Records Release to Delaware Health and Social Services, Division of Public Health:

Screening Assessment

Screening Assessment / Age Range

Screening Assessment / Birth to age 1

Screening Assessment / Age 1 to 12

Screening Assessment / Age 13 to 18