• Cass County Dental Clinic Teledentistry 2025 Enrollment Form

    Please fill out this form for each individual patient. Please do not continue if the form states you are not eligible for our services. If you have questions regarding eligibility, please give us a call- 816-322-7600. *Please note that you must submit all information at the same time. You will not be able to start enrollment and come back to it at a later time.

  • Please select what you know to be true of the patient.

    Medicaid is NOT considered private insurance.

  • Please select what you know to be true of the patient.

  • Please select what you know to be true of the patient.

    If you have already stated you are active with MO Medicaid, please select that choice again and move forward with the form.

  • Patient Information:

  • Patient Sex*
  • Patient Preferred Pronouns*
  • Patient Date of Birth*
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  • Patient Race*
  • Patient Ethnicity*
  • Patient Preferred Language*
  • Does the patient have any other dental insurance?*

  • Parent/Guardian Information:

    The Responsible Party must be the patient’s parent or legal guardian and is the person who is the primary contact for the patient. Guardianship papers must be on file prior to the patient’s appointment. Please fax to 816-322-7606 or email to info@casscountydentalclinic.org.
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  • Parent/​Guardian Preferred Contact Method*
  • Relationship to Patient*
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  • Patient Medical History:

  • Does this patient have a Primary Care Provider?*
  • Is the patient under the care of a physician for anything other than routine check-ups?*
  • Has the patient ever been hospitalized, had a major operation, or a heart procedure?*
  • Is the patient on a special diet?*
  • Has the patient had a serious head or neck injury?*
  • Has the patient ever been told to take antibiotics (pre-medicate) for dental appointments?*
  • Does the patient use tobacco, nicotine, cannabis, or controlled substances?*
  • Is the patient pregnant, trying to become pregnant or nursing?*
  • Anxiety*
  • Autism/​Spectrum Disorder*
  • Autoimmune Disorder*
  • Behavior Issues (ADD/​ADHD)*
  • Bleeding or Clotting Disorder*
  • Breathing or Lung Problems*
  • Cancer*
  • Diabetes*
  • Epilepsy or Seizures*
  • Genetic Disorder*
  • Heart Defect or Disease*
  • Other Condition*
  • Does the patient have any known allergies?*
  • Does the patient take medications?*
  • Do you consent to the application of Fluoride? Fluoride (There are two different types of fluoride that may be used. Fluoride varnish is the sticky substance painted on all the teeth to help make them stronger and prevent cavities. This is a standard part of preventive appointments. Silver Diamine Fluoride (SDF) is a special fluoride used to stop cavities that have already started. It is only applied to specific areas on teeth that appear to have cavities. SDF may turn the cavity brown or black. Treatment with SDF usually requires follow-up at one of our dental clinics so the dentist can place a tooth-colored filling over the top of it.)*
  • Do you give permission for your child’s name and likeness (photo, video, electronic image, &/​or voice recording) to be used in print or electronically published & distributed by Cass County Dental Clinic and its affiliates?*
  • Should be Empty: