School-Based Dental Care Request Form

School-Based Dental Care Request Form
Child Information
Child Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
School Name
Grade Level
Does you or your child have dental insurance?

Other
Parent/Guardian Information
Phone Number
Format: (000) 000-0000.
Email Address
Parent/Guardian Full Name

First NameLast Name
Teacher Name
Is your child currently experiencing any of the following dental concerns? (Check all that apply)
Please provide any additional details about your child’s dental concerns:
Please check any medical conditions your child has:
Is your child currently taking any medications? If yes, please list them below
If yes, please provide the name of the dental insurance provider (e.g., Medicaid, Delta Dental):
Upload your insurance card here(Front and back, screenshot or photo accepted)

Cancelof
The following services will be provided as part of this school-based Sevice:

Dental screenings
X-rays
Fluoride treatment
Cleanings
Sealants (if eligible)
I authorize Teaching Tiny Teeth to provide dental hygiene services to my child?
Should be Empty:

Child Information