Dental Consent & Health History Form

Dental Consent Form

"No Additional Cost"
K12 Mobile Dental and Smiles of Tomorrow
Organization | School Name*
Dental Cleaning Date:*

MonthDayYear
Time

00:00 AM/PM Minutes

AM/PM Option
Our Mobile Dentistry program includes a full exam, cleaning, fluoride and sealants if needed. For any further treatment, anadditional consent will be given and a call will be made by Smiles of Tomorrow.
*Child's Information
Child's Full Name: *
Date of Birth*

MonthDayYear
Age*
Sex
M=Male , F=Female
Teacher's Name:*
Grade Level:*
Class Room No.
Child/Patient's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child/Patient's Phone No.:*
Medical Identification No.:
Medical ID Number (or any other insurance)
PRIVATE INSURANCE

*Information about the health insurance holder.
Full Name (Health Insurance Holder)
Parent/Guardian
Date of Birth (Health Insurance Holder)

MonthDayYear
Name Health Insurance Company?
Example: Blue Cross, Malina, etic.
Name of Employer?
Name of Employer that is covering health Insurance.
Insurance Identification Information?:
Insurance Card No. or SS#
Health Insurance Policy No.?:
Medical History

Medical History of Patient.
HAVE YOU HAD OR BEEN AROUND ANYONE WITH COVID-19 WITHIN THE LAST (10) DAYS?*

YesNo
Other (or please list any conditions/allergies)*

Fever or ChillsCoughShortness of Breath or Difficulty BreathingRheumatic FeverHeart DiseaseAsthmaEpilepsyDiabetesHay FeverCancerSeizure DisorderCerebral PalsyHepatitisHeart MurmurKidney or Liver FailureTuberculosisProfuse BleedingBladder DisorderLatex AllergiesNon ApplicableOther
Does your child have learning or emotional impairments? lf yes, please explain?
Type, Yes and explain condition (If Applicable). If not, please type, "N/A".
IF FURTHER TREATMENT IS NEEDED, YOU WILL RECEIVE A CALL FROM SM I LES OF TOMORROW TO OBTAIN CONSENT FOR TREATMENT AT A LATER DATE AT YOUR CHILD'S SCHOOL
YES, I give my permission for my child to receive: Fillings (white fillings), Extractions, Pulpotomies and local anesthesia if needed. I am the patient or the responsible party for the listed patient. I hereby authorize K-12 Mobile Dental and SOT to provide the dental treatment described. I authorize K-12 Mobile Dental and Smiles of Tomorrow to access my dental records and findings. I authorize K-12 Mobile Dental and SOT to bill on my behalf, and to use Medicaid (or other insurance)/Delta Dental insurance information for billing purposes. By signing this document, the patient, parent, authorized representative and/or guardian further acknowledges that they understand that treatment obtaining duplicate services at a mobile dental facility may affect benefits that he or she receives from private insurance, a state or federal program, or other third-party provider of dental benefits.

*Patient will be seen again in 6-months for follow-up service *
PATIENT'S SIGNATURE : PARENT

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DATE

MonthDayYear
Date
BY SIGNING THIS FORM, I UNDERSTAND THAT: HIPPA COMPLIANCE: PROTECTED HEALTH INFORMATION MAY BE DISCLOSED OR USED FOR TREATMENT, INSURANCE,OR HEALTHCARE OPERATIONS.
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K12 Mobile Dental | A School-Based Program | Office Phone No. (866)417-3701
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Dental Consent Form

K12 Mobile Dental and Smiles of Tomorrow

*Child's Information

PRIVATE INSURANCE

Medical History

IF FURTHER TREATMENT IS NEEDED, YOU WILL RECEIVE A CALL FROM SM I LES OF TOMORROW TO OBTAIN CONSENT FOR TREATMENT AT A LATER DATE AT YOUR CHILD'S SCHOOL

SUBMITNOW