2025-2026 Dental Consent Form

2025-2026 Dental Consent Form
Maine Oral Health & Wellness

maineoralhealthandwellness@gmail.com,

207-542-3079

https://maineoralhealthandwellness.com
Maine Oral Health & Wellness Services
IPDH & Dentist Services: screening, x-rays, caries risk assessment, caries detection, prophylaxis, fluoride application, nutritional counseling, oral hygiene instruction, sealants, interim caries arresting medicaments, re-mineralization treatments, protective restoration (temporary filling/s), dentist examination via tele dentistry & referrals. When available: dentist examination, filling/s, extraction/s in the dental RV at school. Referrals may be made when necessary and a copy will be provided.
Student Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
School
Parent / Guardian Name

First NameLast Name
Address

Mailing Address

Street Address Line 2

TownState / Province

Zip Code
Cell Phone
Email
example@example.com
Payment Choice:
Would you like more information about our sliding scale to qualify for reduced or free services ?
Insurance Subscriber Name (Family member the plan is under )
Subscriber Date of Birth
Insurance Carrier ( Mainecare, Delta Dental, Anthem, Cigna )
Insurance ID # :
Insurance Group # :
Insurance Plan Name / Employer :
Insurance Card Photo Front

Cancelof
Insurance Card Photo Back

Cancelof
Last Dental Appointment :
Last Dental Office Seen :
Medical Conditions

ADDADHDAutismAnxietyCancerDiabetesType option 7Heart ProblemsKidney DiseaseLiver DiseaseAutoimmuneOther
List Medications
List Allergies: Milk, Environmental, Gluten, Latex, Medication, Iodine, Sulfur, Silver, Trees, Other
Does Your Child Require Antibiotics Prior to Dental Procedures ?
Consent To Treat :

Please read #1 - #4
#1 - I give permission for my child to receive all of the above listed services, unless otherwise instructed by me, the parent/guardian, to be provided by the: (IPDH) independent practicing dental hygienist, (PHSH) public health dental hygienist and/or dentist.

#2 - I give permission for Silver Diamine Fluoride (SDF) (interim caries arresting medicament) to be placed on areas of decay. I have read and understand the information on page 2 of this consent form.

#3 - I give permission to request or release confidential information on the above-named child for the purposes of accessing eligibility, obtaining a health screening, providing care and in making referrals for the benefit of the child. This applies to information exchanged to and from the school nurse and to the dentist whom your child is being referred to.

#4 - I understand it is my responsibility to contact the nurse or this program if my child has had a dental appointment in a dental office before this program sees my child. I understand if my child does not qualify for this service, I will be notified, and the consent form will be shredded. I understand that the dental hygiene services that will be delivered by an IPDH or PHDH does not constitute permanent restorative care or treatment, unless our dentist is available for an examination and/or treatment that day.

#5 - I understand that after my child receives care with this program, I may be given a referral, and it is my responsibility to seek that care if the child needs to be seen by a dentist or other specialist for further evaluation and treatment.
Photo Consent: I give permission for MOHW to take a photo of my child. I understand that it may be used on their website, in grant applications, and reports, brochure, as well as other media purposes to promote the services of MOHW provides.
Print Parent/Guardian Full Name
Date

MonthDayYear
Date
Phone number
Signature

Clear
HIPAA Policy Disclosure: This personal information will not be shared with anyone other than the person listed on the "Parent/Guardian Consent to Treat", without a HIPAA request form. If you would like a copy of our HIPAA Policy, it can be requested.
Additional Information Regarding Services We May Provide To Prevent and/ Reduce Dental Disease
Temporary Filling Policy/ Protective Restoration: A temporary filling is not a permanent fix. You still need to take your child to have the temporary filling evaluated, unless our program dentist has not already done so. If your child does not see a dentist, their condition could get worse. Early Caries Treatment: We don't watch areas; we treat early caries to prevent further breakdown and remineralize the tooth structure whenever possible to reduce the need for drilling, filling or extractions. We will be using either Vvardis Curadont or Silver Diamine Fluoride to accomplish this.

Vvardis Curadont - A unique drill-less and pain-less brush on application, minimally invasive procedure. Backed by over 20 years of research and development, the innovative biomimetic vVARDIS technologies mimic nature to treat early caries and help protect against their initiation. They can diffuse into the enamel helping minerals like fluoride together with calcium and phosphate from saliva to foster remineralization. This can be applied on all surfaces of a tooth, wherever there is early caries starting, including around orthodontic brackets.

Silver Diamine Fluoride - A drill-less and painless brush on application. Only requires dry area to be treated for at least one minute. May be applied 2x at least 6 weeks apart for best results.

Benefits of Silver Diamine Fluoride

Helps to stop the progression of cavities Stains visible and hidden tooth decay for you to see Is a No Needle/No Drill alternative SDF treatment can help stop tooth pain No known side effects other than cavity staining

What to Expect SDF only stains cavities, not healthy parts of a tooth Treatment helps stop the spread of disease. Treatment provides time to seek additional dental care for your child. The tooth staining associated with SDF can takes days to appear. If SDF inadvertently touches your child's skin, you will see temporary tattooing. This is not a health concern and will fade within 2-3 days.
Should be Empty:

2025-2026 Dental Consent Form

Maine Oral Health & Wellness Services

Consent To Treat :

Additional Information Regarding Services We May Provide To Prevent and/ Reduce Dental Disease