• Dental Sealant Permission Slip

    Partnership Community Health Center is offering a preventive dental sealant program for ALL children in Daycare, Headstart, 3K, 4k, K, Elementary, Middle and High school. This program is funded by the Wisconsin Seal-A-Smile, a collaborative program of Children’s Health Alliance of Wisconsin and the Wisconsin Department of Health Services. A licensed dental provider will come to the school to provide the sealant program at no charge to you. The program includes: assessment to determine if sealants can be done, sealants if appropriate, fluoride treatments and tooth brushing instructions with a new toothbrush. A follow-up letter will be sent home to describe what was completed and what is recommended for future needs. All procedures will follow recommendations from the American Dental Association and Centers for Disease Control and Prevention’s recommendations for school based dental sealant programs. This permission is effective for [24 months in order to replace lost sealants when checked after one year or to have sealants applied on teeth that were not sealed this year.

  • Child Information

  • Child Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Consent and Parent/Guardian Authorization

  • Consent to Participate and Authorize Billing*
  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Insurance Information

  • Subscriber Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Ethnicity and Race

  • Race

  • Medical History

  • Does your child use medicine prescribed by a doctor?*
  • Does your child need or use more medical care than other children the same age?*
  • Does your child have trouble doing things most children the same age can do?*
  • Does your child need or get special therapy (physical, occupational, speech, etc.)?*
  • Does your child need counseling or treatment for behavior or emotional problems, or delays in walking, talking, or activities?*
  • Has this problem lasted or is it expected to last at least 12 months?*

  • Allergies and Dental History

  • Does your child have any allergies?*
  • Has your child been seen by a dentist?*
  • Should be Empty: