Dental Consent for Treatment

Dental Consent for Treatment
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Grade*
YES, I give permission for my child to be examined and treated by a Big Sandy Health Care dentist, dental hygienist and staff at the school or on a Mobile Dental Unit located on school property.

1.    I understand that my child’s teeth will be examined by a qualified Big Sandy Health Care dentist.

2.    I understand that the dental exam may include the use of digital dental x-ray equipment (digital x-rays generally result in less radiation exposure than traditional film).

3.    I understand that preventive services, which may include cleaning and application of fluoride and sealants, may be provided by the dental hygienist without the presence of, but under general supervision of and according to a plan ordered by a dentist.

4.    I understand the examination may determine that more treatment is needed beyond that which can be performed at the school or on the Mobile Dental Unit. I understand that, if indicated, Big Sandy Health Care will assist in referring my child to another dentist.

5.    While all the individual dental records are held by Big Sandy Health Care as confidential, I understand that a list of children who need follow up dental treatment may be routinely provided to the school’s family resource center.

6.    If my child is insured by an Avesis plan, I give my permission for an Avesis representative to return to the school within 365 days to check my child's dental sealants (if applicable).

CONSENT TO TREATMENT: I authorize the examination of my child by a Big Sandy Health Care dentist, including the performance of diagnostic digital x-ray. I authorize the provision of preventive care procedures by a Big Sandy Health Care dentist, dental hygienist and staff, as may be necessary or beneficial.

RELEASE OF INFORMATION: I understand that the dental records and x-rays that are associated with my child’s evaluation and care are the property of Big Sandy Health Care. I authorize Big Sandy Health Care and its staff to release pertinent information from the patient’s record to any insurance company or agency which may be responsible for the fees for services rendered. In the event a Big Sandy Health Care dentist refers my child to another dentist, I authorize the release of my child’s dental records to that dentist (referral dentist). In addition, I authorize the referral dentist to release my child’s dental records to Big Sandy Health Care.

PAYMENT AUTHORIZATION: I hereby authorize insurance payment directly to Big Sandy Health Care of the benefits that might otherwise be payable to me. I understand that I will NOT be required to pay for services.
Signature of Parent/Guardian*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Contact Email
example@example.com
Dental Registration

I understand that Big Sandy Health Care, Inc. shall provide a copy of its Notice of Privacy Practices upon my request, which is also available at www.bshc.org. By signing this form, I give consent for my child’s dental insurance to be billed.
School*
Grade*
Teacher*
Student Information
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Social Security Number (Required)*
Child's SSN
WhiteBlack or African AmericanAsianNative American or Alaska NativeNative Hawaiian or Pacific Islander
Hispanic or LatinoNon-Hispanic or Latino
EnglishSpanishOther
As a Federally Qualified Health Center, Big Sandy Health Care is required to collect the following information to ensure we are providing the appropriate medical care and financial assistance, as needed.
Number of people in household*
Annual Household Income*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Date of Birth*

MonthDayYear
FatherMotherGuardianFoster ParentStep ParentOther
Parent/Guardian Social Security Number*
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Information
Dental Insurance Name
ID Number
Dental Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Social Security Number
Patient Consent to Share Personal Health Information

Please list anyone Big Sandy Health Care, Inc. could share the patient's medical information with.
Person 1

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

MonthDayYear
Date
Person 2

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

MonthDayYear
Date
Person 3

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

MonthDayYear
Date
Medical History
Is your child allergic to any medication?*
Please List Any and All Allergies (Food/ Environmental) with Type of Reaction
Does your child take any medication? *
If yes, please list each medication with current dose
No Medical HistoryADHDAnemiaAnxietyAsthmaAutismBlindness/Vision LossDeafness/Hearing LossDepressionDiabetes Type IDiabetes Type IIHeart MurmurHypertension/High Blood PressureHypothyroidismMigrainesDevelopmental DelaySpeech DisorderBleeding DisorderCongenital Heart Problem
Please List Any Other Medical Conditions, Behavioral Health Condition, or Prior Surgeries Below
Family History

Please label below with : M for Mother, F for Father, S for Sibling, and G for Grandparent.
ADHD M, F, S, or G Asthma M, F, S, or G
Heart DiseaseM, F, S, or G   Mental/Emotional Disorder (Depression, Bipolar, Anxiety)M, F, S, or G
Diabetes Type IM, F, S, or G   Diabetes Type IIM, F, S, or G
HypothyroidismM, F, S, or G
Heart MurmurM, F, S, or G
Blood DisorderM, F, S, or G   CancerM, F, S, or G
High Blood Pressure   M, F, S, or G High Cholesterol Unexpected or unexplained death before age 35?   M, F, S, or G
Do you have well water?*
Does your child use fluoride toothpaste?*
How often does your child consume sugary foods/drinks?*
How long has it been since a member of your child’s family had a cavity?*
How often does your child see the dentist?*
If you have a dentist that sees your child regularly, please provide the dentist’s name:
Is there anything else we should know about the dental care he/she has had in the past? If so, please explain.
By signing this form, I agree that the above information is correct to the best of my knowledge.
Child's Name*

First NameMiddle NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Dental Registration

Student Information

As a Federally Qualified Health Center, Big Sandy Health Care is required to collect the following information to ensure we are providing the appropriate medical care and financial assistance, as needed.

Dental Insurance Information

Patient Consent to Share Personal Health Information

Medical History

Family History

By signing this form, I agree that the above information is correct to the best of my knowledge.