Free Dental Services Permission Slip

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.
Name of Child*

First NameLast NamePreferred Name
Child's Date of Birth*

MonthDayYear
Date
Child's School:*
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):*

Yes, to screening, sealants, and fluorideYes, to screening and sealantsYes, to screening and fluorideYes, to screening onlyNo, do not provide any dental services for my child
If yes, please complete and sign below
Parent/Guardian Name:*
Phone Number:*
Please enter a valid phone number.
Permission to text:

YesNo
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide the following information so we can better serve your child:
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:
Please complete the section below. You will not receive a bill.

All services are FREE!
Health Insurance:

Oregon Health Plan (OHP)Private dental insurance companyNo health insurance
OHP Medicaid ID# (if applicable)
Name of private dental insurance company(if applicable)
Gender:
Ethnicity:

Mexican, Mexican American, or Chicano/aAnother Hispanic, Latino/a, or Spanish OriginMultiple Hispanic, Latino/a, or Spanish OriginNon-Hispanic or Latino/aCubanPuerto RicanUnknownRefuse to disclose
Race - Please check all that apply:

Alaskan NativeAmerican IndianAsian IndianChineseFilipinoJapaneseKoreanVietnameseSamoanNative HawaiianOther Pacific IslanderOther AsianGuamanian or ChamorroBlack/African AmericanWhiteUnknownRefuse to disclose
Language:
Employment Type:

Farm work that doesn't require moving your homeFarm work that requires moving your home at least once per yearNon-farming, non-seasonal workOther
Household Income
Total household income for previous month: $ blanks
Number of people this income supported: blank
Housing Status

Not homelessAt risk for homelessLiving with othersHomeless, unknown shelterCurrently not homeless, was in the last 12 monthsStreet, camp, bridgeLiving in a shelterTransitional housingChild at Risk for HomelessPermanent Supportive HousingVeteran at Risk for HomelessSingle Occupancy Home
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/.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

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.