Dental Consent English

49% of students screened had treated or untreated cavities.

Free dental screenings, sealant placements, and brushed-on fluoride are now offered at your child’s school. Signed permission lasts for up to 24 months. These services are done by dental care professionals and help prevent cavities.

Check ONE below to sign up for this free service:

Check ONE below

Name of Child

First NameLast Name

Child's Date of Birth (mm/dd/yy)

Date

School

Grade

Teacher

Check all that apply to your child

My child is taking (list medications)

My child is allergic to:

Any current medical problems

Any behavioral considerations

Other information to help us better serve your child

Health Insurance. Complete the section if you are able. You will not receive a bill.

Health Plan Name and Medicaid ID

Insurance Company NameMedicaid ID

Private Health Plan Name and ID

Insurance Company NameID number

Parent / Guardian Name

First NameLast Name

Contact Information

Phone NumberEmail

Mailing Address

Street AddressCity, State, Zip Code

By signing below you agree:

As the legal parent/guardian, I consent for 24 months to the release and sharing of information, including personal health information, between the dental sealant staff, school staff, insurance carriers, the child’s dentist, applicable Coordinated Care Organization, and/or the Dental Care Organization of record. I understand that my child’s school may not supervise my child or dental staff during the time of this consented procedure. I have received a copy of “Notices of Privacy Practices,” also available on the All Smiles Community Oral Health website AllSmilesCOH.org/forms. I understand that a dental student closely supervised by a licensed professional may provide treatment.

Parent/Guardian Signature