Mobile Dental Consent Form

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 NameMiddle NameChild's Last Name
School Name*
Grade
Teacher's Name

First NameLast Name
Date of Birth*

MonthDayYear
Sex
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race

WhiteBlack / African AmericanAsianAmerican Indian / Alaska NativeNative HawaiianOther Pacific IslanderChoose Not to DiscloseOther
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoUnreported/Choose Not to Disclose
Language

EnglishBurmeseSpanishOther
Parent/Guardian Information

Please fill out information for Parent/Guardian
Parent/Guardian 1 Name*

Parent/Guardian First NameParent/Guardian Last Name
Date of Birth*

MonthDayYear
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?*

YesNo
Dental Insurance Provider
Patient's Primary Dentist

First NameLast Name
Has the patient had a cleaning within the last 6 months?

YesNo
Patient Medical History
Child's Primary Medical Provider Name:
Name of Child's Medical Provider
My Child Takes Medicine*

YesNo
If Yes, Please List:
Please list all of the child's medications.
My Child Has Allergies*

YesNo
If Yes, Please List:
Please list all of the child's medications.
My Child Has Asthma*

YesNo
If Yes, is inhaler needed at time of dental visit?

YesNo
Does your child have heart problems such as artificial heart valve, previous endocarditis, damaged (scarred) heart valves, congenital heart defects, or heart transplant?*

YesNo
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.

YesNo
I consent and authorize Grace Health to use Silver Diamine Fluoride to help stop tooth decay.
Should be Empty:

Mobile/Portable Dental Services Consent Form

Patient Information

Parent/Guardian Information

Dental Insurance Information

Patient Medical History

Consent for Silver Diamine Fluoride Treatment