School-Based Oral Health Forms

School-Based Dental Consent to Treat Form

Mountain Community Health Partnership

School-Based Dental Consent to Treat Form
As the parent/guardian of the student, I understand that through MCHP Bakersville Dental Center School-Based Oral Health Program, a Public Health Dental Hygienist will be coming to my child's school to provide a Dental Screening and, as needed, a Dental Cleaning, Fluoride Treatment, and Dental Sealants.

Dental sealants, in addition to regular brushing and flossing, protect your child's teeth from cavities. Dental sealants are a thin, plastic coating that is put on the tops of the back teeth to seal out food and germs. Sealant(s) is applied on teeth that appear to not have a cavity, and they don't hurt. Program services do not include drilling or shots.

I authorize MCHP Bakersville Dental Center to perform the above necessary procedures. I'm aware that these services are not free, and MCHP Bakersville Dental Center will bill your child's dental insurance. I'm also aware that if my child does not have dental insurance, I may apply for MCHP Bakersville Dental Centers Sliding Fee Discount by contacting the dental center at (828) 537-5991.

By signing below, I confirm that I understand this form and the information disclosed.
Please select if you would like your child to participate in this program:*

YES, I want my child enrolled in this programNO, I do not want my child enrolled in this program
Name of Student*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Race/Ethnicity, please select all that apply*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteHispanic or Latino or Spanish OriginNot Hispanic or Latino or Spanish Origin
Name of school the child attends:*
Grade the child is in:*
Name of Parent/Guardian/Conservator*

First NameLast Name
Relationship to student:
Phone Number
Signature of Parent/Guardian/Conservator*

Clear
Date*

MonthDayYear
Date

SDF (Silver Diamine Fluoride) Consent Form -Optional

Mountain Community Health Partnership

SDF Optional Consent Form
Facts for Consideration:
- Silver diamine fluoride (SDF) is a liquid that helps stop tooth decay. SDF is applied every 3, 6, or 12 months.
- A small amount of SDF is applied to the decayed tooth area.
- After SDF application, there should be no eating or drinking for 60 minutes and no tooth brushing until the following morning.
- The decayed area will stain black permanently. Healthy tooth structure will not stain.
- I should not be treated with SDF if:I am allergic to silver. There are painful sores or raw areas on my gums or anywhere in my mouth.
Benefits of Receiving SDF
- Helps stop tooth decay.
- Fast acting.
- No need to numb teeth/jaws.
- Does not hurt.
Risks of Receiving SDF
- The affected area will stain black permanently. This means SDF is working.
- Tooth-colored fillings & crowns may discolor if SDF is applied to them.
- After SDF treatment, a filling or crown might still be needed.
- If accidentally applied to the skin or gums, a brown or white stain may appear that causes no harm, cannot be washed off, and will disappear in one to three weeks.
- Permanent dark spots if spilled on clothing.
- Allergic reaction.
- A risk that the procedure may not stop the tooth decay.
- Not every cavity can be treated with SDF.
Alternatives to SDF are not limited to the following:
- No treatment, which may lead to the continued breakdown of the tooth. Symptoms may worsen.
- Placement of fillings or crowns, extractions, or referral to a specialist.
I have read this form and understand the treatment. I have had the chance to ask questions, and I have seen the photo of how teeth may look after SDF discolors the cavities. I understand that I may refuse treatment with SDF. I understand that I can decide to have no treatment, or I can have fillings, crowns, or extractions done at this or another dental office.

I, the patient/parent/guardian, hereby give my consent to the undersigned provider and authorize MCHP Dental Health Center to use Silver Diamine Fluoride to help stop tooth decay.
Signature of Parent/Guardian/Conservator

Clear
Date

MonthDayYear
Date

Insurance Verification Form

Mountain Community Health Partnership

Insurance Verification Form
Insurance Subscriber Name*

First NameLast Name
Subscriber Birthdate*

MonthDayYear
Date
Subscriber Phone Number*
Subscribers' Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Student
Please upload a photo of the front of your insurance card:

Cancelof
Please upload a photo of the back of your insurance card:

Cancelof
If you cannot add photos of your insurance card, please complete the following:
Private Insurance Name of Company:
Private Insurance Company Phone #:
Group #
Insurance ID #
Parent/Guardian/Conservator Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

School-Based Dental Consent to Treat Form

SDF (Silver Diamine Fluoride) Consent Form -Optional

Student Medical History

Insurance Verification Form

If you cannot add photos of your insurance card, please complete the following: