Mobile/Portable Dental Services Consent Form
This consent form is authorizing Grace Health staff to provide dental services.
Patient Information
Child's Name
*
Child's First Name
Middle Name
Child's Last Name
School Name
*
Grade
Teacher's Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Sex
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
White
Black / African American
Asian
American Indian / Alaska Native
Native Hawaiian
Other Pacific Islander
Choose Not to Disclose
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unreported/Choose Not to Disclose
Language
English
Burmese
Spanish
Other
Parent/Guardian Information
Please fill out information for Parent/Guardian
Parent/Guardian 1 Name
*
Parent/Guardian First Name
Parent/Guardian Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone Number
Please enter your home phone number.
Format: (000) 000-0000.
Daytime Phone Number
Please enter a number to contact you during daytime.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Name
Home Phone Number
Please enter your home phone number.
Format: (000) 000-0000.
Daytime Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Dental Insurance Information
Does the Patient Have Dental Insurance?
*
Yes
No
Dental Insurance Provider
Patient's Primary Dentist
First Name
Last Name
Has the patient had a cleaning within the last 6 months?
Yes
No
Patient Medical History
Child's Primary Medical Provider Name:
Name of Child's Medical Provider
My Child Takes Medicine
*
Yes
No
If Yes, Please List:
Please list all of the child's medications.
My Child Has Allergies
*
Yes
No
If Yes, Please List:
Please list all of the child's medications.
My Child Has Asthma
*
Yes
No
If Yes, is inhaler needed at time of dental visit?
Yes
No
Does your child have heart problems such as artificial heart valve, previous endocarditis, damaged (scarred) heart valves, congenital heart defects, or heart transplant?
*
Yes
No
I acknowledge that I have received a copy of Grace Health’s Notice of Privacy Practices. I was able to ask any questions I hadregarding the information above and have been given satisfactory answers to all my questions, in a way I can understand.
*
Consent for Silver Diamine Fluoride Treatment
I HAVE READ AND UNDERSTAND THIS FORM. ALL OF MY QUESTIONS ABOUT TREATMENT, INCLUDING THE BENEFITS, SIDE EFFECTS, AND RISKS WERE ANSWERED.
Yes
No
I consent and authorize Grace Health to use Silver Diamine Fluoride to help stop tooth decay.
Submit
Should be Empty: