Dental Consent - FORM A

Your child's school is offering preventative oral health care services. 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.

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 Permit hygienists will be coming to provide dental cleanings, fluoride varnish, and sealants.

If you would like to sign your child up for Extended Care Services (cleaning, fluoride varnish, and sealants*) please complete this online form.

* 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.

**If your child already sees a dentist regularly & you do not wish to switch, do not complete this form**

Preventive services: GraceMed Health Clinic is providing in-school dental care including dental exams, x-rays as needed, cleanings, sealants, silver diamine fluoride and fluoride varnish. All children are invited to participate in the program, but the program has a special focus on those children not receiving services elsewhere. No child will be denied services based on insurance status or ability to pay. However, insurance (if available) will be billed.

Restorative services (fillings & extractions of infected baby teeth): Not same day of preventive services. There is no out-of-pocket cost if you have KanCare/Medicaid or private insurance. All claims will be filed with your insurance. If uninsured, you must qualify for the free/reduced lunch program and an upfront cost of $60 per filling/extraction will apply on day of service.
School Name
Grade
Student Name
Gender

MaleFemaleOther (Specify)
Specify Gender
CURRENT DATE

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Age
Phone #
Social Security Number (Last 4 Digits)
XXX-XX-_________
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 (Choose One)

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

In the past 6 monthsIn the past yearMore than a yearNever
Does your child qualify for free/reduced lunch program at school?

YesNo
Insurance Coverage
Confirm: No Insurance

No Insurance
KanCare Number
001_____________________
Private Dental Insurance Carrier
Policy Number
Group Number
Policy Holder Name
Policy Holder DOB
Policy Holder SSN
Medical Conditions (Check all that apply)

Artificial Heart ValveHeart Trouble/DiseaseAsthmaHeart MurmurArtificial JointDiabetesCongenital Heart DisorderHepatitisSeizure DisorderAutismADHD
List any known allergies
Other medical conditions or special health care needs
Please list all current medications
Is your child required by a physician to take a pre-medication (antibiotic) prior to dental treatment?

YesNo
If yes for what condition and what medication does your child take and how much
DISCLAIMER: 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
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