Dental Consent - FORM D

Kansas State Statute 72‐6251 requires all students enrolled in Kansas schools to receive a free dental screening each year. In accordance with this, GraceMed will be providing this service at your school.

Oral health is an important part of children’s overall health and is a critical component in the child’s ability to learn and succeed in school. This screening does not replace the exam provided by your dentist.

If you wish to opt out of the screening, please contact your nurse.

Although passive consent is implied if your school nurse is not contacted, as a parent you have options concerning your child’s dental health. At a minimum, screening is always recommended and does not replace an exam provided by a dentist.

A copy of the screening results will be sent home with the child.

If you wish to sign up for expanded care (cleaning, fluoride varnish, sealants) please fill out the information below. A report will go home with the student on any expanded care received. No sign up is needed for screenings only.

Consent for In-School Dental Care

Preventive services: GraceMed provides in-school dental care including cleanings, sealants, 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 in a dental office. No child will be denied services based on insurance status or ability to pay. However, insurance (if available) will be billed.

**If your child already sees a dentist regularly, please do not complete this form**
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 Race
Ethnicity (Choose One)

Hispanic / LatinoNot Hispanic / Latino
When did your child last visit the dentist?

In the past 6 monthsIn the past yearMore than a yearNever
What is the name of the dentist you go to?
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
Should be Empty: