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  • Permission Slip for Free Dental Services

    Free dental screenings, sealant placements, and brushed-on fluoride are now offered at your child’s school. These services are done by dental care professionals and will help prevent cavities.
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  • Dental Screening: a quick look inside the mouth to check the overall health of teeth.

    Dental Sealants: coatings put on the student's back teeth to prevent cavities.

    Fluoride: brushed on teeth, this vitamin makes teeth stronger and prevents cavities.

  • If yes, please complete and sign below

  • Please provide the following information so we can better serve your child:

  • Please complete the section below. You will not receive a bill.

    All services are FREE!
  • Household Income
    Total household income for previous month: $
    Number of people this income supported:

  • By signing below, as the legal parent/guardian, I hereby consent to the release and exchange of information, including any relevant personal health information, between the dental sealant staff, school staff, insurance carriers, the child's dentist, applicable Coordinated Care Organization, and /or the Dental Care Organization of record. I have received a copy of "Notices of Privacy Practices." Privacy Practices are available on the Dental3 website http://dental3.net/forms/.
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