Dental Consent - FORM C

Your child’s school is offering preventative oral health care services. Dental Screenings and Extended Care Services are being held at schools during the 2024-25 school year. You will receive a notification in the future when a date has been set.

School screening and extended care services DO NOT take the place of a dental exam or include x-rays. Please continue to see your dentist regularly.

Screenings

All students in Wichita Public Schools will receive a dental screening unless they have given a completed dental card to the school nurse stating that they have received a recent dental exam. If your child already receives routine care every six months, please notify the school nurse and continue to see your dentist for regular cleanings and check-ups!

If your child is referred to a dentist for an exam, please call your school nurse if you need help with making a dental appointment.

Extended Care Services
Extended Care Permit hygienists will be coming to provide dental cleanings, fluoride varnish, and sealants. No x-rays, exam, or restorative services such as fillings or tooth removal will be provided.

If you would like to sign your child up for Extended Care Services (cleaning, fluoride varnish, and sealants*) please fill out the back side of this form and return it to the school nurse as soon as possible.

*Sealants are thin plastic-like coatings placed in the pits and grooves of permanent molars to reduce risk of getting a cavity. A properly sealed tooth is up to 50 percent less likely to develop a cavity in the future.

If dental services are provided for your child in the school, you will receive a report stating what services your child received. On occasion, a Wichita State University senior dental hygiene student may accompany and assist usdental event.
Dental Consent Form
Consent Form Email
example@example.com
School District
School Name
Grade
Student Name
Gender

MaleFemaleOther (Specify)
Specify Gender
CURRENT DATE

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Age
Phone #
Social Security Number
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Parent Name
Email
example@example.com
Race (Check all that apply)

AsianAmerican Indian / Alaska NativeBlack / African-AmericanNative HawaiianOther PacificCaucasian / WhiteOther RaceDecline to Specify
Ethnicity

Hispanic/LatinoNot Hispanic/LatinoDecline to Specify
When did your child last visit the dentist

In the past six monthsIn the past yearMore than a yearNever
What is the name of the dentist you go to
No Insurance?

No Insurance
Does your child qualify for free/reduced lunch program at school

YesNo
Kancare # 001
Private Dental Insurance Carrier
Policy Number
Group
Policy Holder Name
Policy Holder DOB
Policy Holder SSN
List any known allergies
Medical Conditions (check all that apply)

Artificial Heart ValveHeart Trouble/DiseaseAsthmaHeart MurmurArtificial JointDiabetesCongenital Heart DisorderHepatitisSeizure DisorderAutismADHD
Other medical conditions or special health care needs
Please list all current medications
Is your child required by a physician to take a premedication antibiotic prior to dental treatment

YesNo
If yes for what condition and what medication does your child take and how much
I am the parent or legal guardian/custodian and give my consent for above named child to receive any dental treatment considered necessary by the hygienist for the prevention of dental disease. This includes cleanings, fluoride varnish application, and dental sealants. HealthCore, GraceMed, and/or Hunter Health will treat all patients' information as protected health information under HIPAA regulations, exchanging the PHI only with personnel employed by them and the facility/school that are responsible for medical treatment and/or record review. Information from my child's participation in this special event will be utilized anonymously for statistical purposes. The above information is true to the best of my knowledge. This dental outreach consent is in effect for current school year and expires June 1st.
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: