“To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my student’s health, and understand that it is my responsibility to contact the dental provider at (217)531-4279 if any changes occur in my child’s medical status. I give permission for my child to be seen by a Public Health Dental Hygienist (under the supervision of a licensed dentist).
By signing this form, I give my permission to the Champaign-Urbana Public Health District (CUPHD) Dental Program to treat my student at school during the 2023-24 school year, and also verify that I understand HIPAA and my Privacy Rights, have received copies if I have requested them. This will also give permission for the Illinois Department of Public Health Quality Assurance Audits to be performed, and permission for my student’s school to provide additional contact information for me to CUPHD as needed to discuss dental treatment.”