ENGLISH 2024-2025 School Dental Services Consent

2024-2025 SCHOOL DENTAL SERVICES CONSENT (A)
Your student’s school has arranged for the Champaign-Urbana Public Health District’s Child & Teen Dental
Clinic to provide dental services at school during the school day with NO COST to you.
Services are open to students in all grades who have Medicaid or All Kids, or who are uninsured.
Services include dental exam, dental sealants, cleaning and fluoride treatment to prevent cavities.
This meets the State of Illinois dental exam requirement.
Please complete the consent below for your student to be seen.
Student's Name*

First NameLast Name
Student's Birthdate*

MonthDayYear
Date
School Name:*
Grade*
Gender*
Pronouns (she/her, he/him, they/them, etc.)
Medical History
Please check any medical conditions your child has or has had in the past:*

NO KNOWN MEDICAL CONDITIONSADD, ADHD or relatedAIDS or HIV PositiveAsthmaAutismBlood or Bleeding DisordersCancerDiabetesEpilepsyHearing or Vision ImpairedHeart Surgery or Heart DiseaseMental DisabilityPhysical DisabilityPregnantSickle Cell AnemiaTuberculosisOther (please explain below)
Please explain OTHER:
Please list any medications you child currently takes: (If none, please type "none".)*
Please list any food/drug/product allergies: (If none, please type "none".)*
“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 2024-25 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.”
Parent or Legal Guardian Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Parent or Legal Guardian Name:*

First NameLast Name
All procedures will be performed by registered Public Health Dental Hygienists licensed to practice in the State of Illinois. A licensed dentist, offsite, will review all records and treatment provided. Results of your child’s dental assessment will be sent home, along with how many sealants were placed. Please note this is a visual assessment with no x-rays taken and should not replace regular dental visits. Do you consent to your child being seen by a Public Health Dental Hygienist?*
Parent or Legal Guardian Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Legal Guardian Email Address*
Parent or Legal Guardian Phone Number*
Please enter a valid phone number.
Student's Race*

American Indian or AlaskanAsianBlack or African AmericanHawaiian or Pacific IslanderOther IslanderHispanic or LatinoWhitePrefer Not to Answer
Student's Ethnicity*

Hispanic or LatinoNon-Hispanic or LatinoPrefer Not to Answer
Does your student have a current dental home?*

YESNO
If YES, what is the name of your dental office?*
Name of Medicaid Dental Insurance (if no insurance, select NO INSURANCE)*
Student's Insurance ID #:
In order to receive dental services, a case manager will be following up with you by phone or email. If you do not respond to the case manager's attempts to reach you, your student will not be seen at the dental clinic.*
If NO INSURANCE, you must answer income questions to determine eligibility. What is your household size?*
If NO INSURANCE, you must answer income questions to determine eligibility. What is your MONTHLY gross income?*
Signature of Dentist/Date
This space is for the dentist to sign and date after reviewing the health history.
Should be Empty:

2024-2025 SCHOOL DENTAL SERVICES CONSENT (A)

Medical History