In-School Smiles Consent Form

In-School Smiles/Tiny Teeth Express Oral Health Program

In-School Smiles / Tiny Teeth Oral Health Program will be providing visual screenings & preventive oral health services at your child's pre-school on. Service choices include oral screenings, fluoride varnish, teeth cleanings, and protective dental sealants.

Dental sealants are offered to children 3 years and older. 18 months to 3 yrs. old may receive cleaning of teeth & fluoride varnish. HeadStart kiddos under 18 months will receive visual screenings only. Our screenings count as ECEAP dental health encounters for enrollment purposes as well.

These visits are quick and fun, your child will receive a free toothbrush & sticker. Every child will receive a free visual screening unless you opt out with your child's school, please inform them if you would like to opt your child out of the screening. *Screenings are NOT the same as dental exams and do not interfere with regular dental office exams*

Teeth Cleaning- removal of soft plaque and debris on all teeth surfaces. *Please note your child's insurance will only cover cleanings every 6 mo./2 times per year,.

Fluoride Varnish is a safe, great tasting "cotton candy" flavored gel brushed onto the teeth by a dental professional which helps fight cavities and is recommended for young children 2-4 times per year.

Dental Sealants are a safe and painless coating placed on chewing surfaces of the back teeth. They may be effective for several years. According to the CDC (Center for Disease Control) sealants prevent cavities by up to 80%!

Silver Diamine Fluoride is a safe, tasteless liquid when placed can actually reverse early cavities and is also used to reduce sensitivity. It is only placed on back teeth as it sometimes will darken the area where a cavity is present. Please visit www.ADA.org for more information.

Please fill information out below for your child to receive preventive services.
Last name*
First name*
Birthdate*

MonthDayYear
Date
Gender*
Childs"s School or Care facility*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Please check all services you would like your child to receive.*

Visual ScreeningTeeth CleaningFluoride ApplicationDental SealantsSilver Diamine Fluoride
Does your child have any allergies, health issues, or neurodiversities ?*

AllergyHealth IssueNeurodiversity or Sensory
Provider One/ Medicaid # (9 digits ending in WA)
Insurance/Payment*
*We can bill your private dental insurance as a courtesy but, cannot guarantee payment.
*If Provider One # not known, leave blank-we can verify with name and date of birth.

ECEAP/Headstart children are 100% covered by Medicaid for our services.

Cash Pay Option- You will be billed after the visit. Balance is due within 14 days of billing. Our low-cost cash pay fees are less than 50% of typical dental office fees and are as follows: Teeth Cleaning $45, Dental Sealants-$20 each (maximum of 8 teeth), fluoride varnish $15

Our experienced licensed dental professionals uphold all CDC safety and infection control standards. No child will ever be forced to complete services. Our mission is to create a positive dental experience to

By signing below, / consent for my child to enroll in the In-School Smiles/Tiny Teeth Express oral health program and receive preventive services. If you wish for your child to be exempt from the screening, please inform your child's center/ school. The Health Insurance Portability and Accountability Act 1996 (HIPPA) requires all health care records be kept confidential. Tiny Teeth Express adheres to all HIPAA standards and will provide Notice of Privacy Practices upon request. Patient/Parent/Guardian Information:
If you checked a box above, please list allergy or concern here:
Parent/Guardian Signature*

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