Free Dental Services Permission Slip

Name of Child

First NameLast NamePreferred Name

Child's Date of Birth

Date

Child's School:

Child's Summer Program (Select "Wichita" if signing up for screenings at Wichita; Select "NA" if not applicable)

Grade:

Teacher:

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.

Please check one box below to sign up for this free service (if more than one box is checked, all approved services will be provided):

Parent/Guardian Name:

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Permission to text:

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My child is taking (list medications):

List medications here

My child is allergic to:

Any current medical conditions:

Any behavioral considerations:

Other information to help us better serve your child:

Health Insurance:

OHP Medicaid ID# (if applicable)

Name of private dental insurance company(if applicable)

Gender:

Ethnicity:

Race - Please check all that apply:

Language:

Employment Type:

Other

Household Income
Total household income for previous month: $ blanks
Number of people this income supported: blank

Housing Status

As the legal parent/guardian, I consent for 24 months to the release and sharing of information, including 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,” also available on the All Smiles Community Oral Health website AllSmilesCOH.org/forms. I understand that a dental student closely supervised by a licensed professional may provide treatment.

Signature

Date

Permission Slip for Free Dental Services

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.