SCHOOL DENTAL HYGIENE PROGRAM – PERMISSION FORM Patient Consent & Medical/Dental History P.O. Box 314 Lewiston, Maine 04243 (207) 513-1111

www.ToothProtectors.org School Name:_______________________________________________________________ Grade:________ Teacher’s Name:_____________________________________________________________

Your child CAN participate in the Dental Hygiene Program – Please choose either OPTION 1 or 2:

1.

If your child receives MAINECARE INSURANCE: (services provided at No Cost)

please check off either A or B and Indicate if you would like X-Rays (bottom of this box) A. ___My child has not been seen in the last 6 months for a dental cleaning and I would like my child to participate and receive a FULL dental cleaning, flossing, fluoride treatment and sealants. B. ___My child already had a cleaning in the last 6 months, but I would like my child to participate and REVIEW proper brushing, flossing, receive fluoride treatment and sealants if needed. (this is NOT a full cleaning and will not interfere with dental care your child is currently receiving at their regular dental office).

CHILD’S MAINECARE ID#__________________________________________ If you would like your child to receive X-RAYS Please check here ____ (this service may not be available at time of clinic). Date of Last X-Ray: ______________ Your Initials:________

2.

If your child has NO DENTAL INSURANCE / UNDERINSURED you can have him/her participate as a SELF-PAY patient: please check off ONE of the following below (If you choose to, your child can participate even if they are currently being seen at a dental office) ___My child is 12 or Under, for $42.00 I would like my child to have a full cleaning, fluoride and sealants if needed. ___My child is 13 to 20, for $52.00 I would like my child to have a full cleaning, fluoride and sealants if needed. ___My child is 1-20, for $10.00 (Does NOT INCLUDE CLEANING), it’s a review of proper brushing, flossing and fluoride

Please send payment to school with this completed permission form – There will be a $20.00 fee for insufficient funds. Method of Payment: __Check __Cash __Money Order/Bank Check - Please make checks payable to: Tooth Protectors Inc or TPI

CHILD’S GENERAL INFORMATION: Child’s Full Name:______________________________________________________________________ Date of Birth:_____/______/_________

Male_____ Female_____

Home Phone:__________________________ Cell:_____________________________

Mailing Address: ___________________________________________________________________________ Zip:_________________

CHILD’S MEDICAL/DENTAL HISTORY: Please List any Medical Conditions your child has:_____________________________________________________________________ List ALL Medications:____________________________________________________________________________________________ Has your child ever needed antibiotics for dental treatment? Y N If yes, please take the same precautions prior to treatment at school My child is allergic to:______________________________________________________________________________ Physicians Name:_______________________________________________ Does your child take fluoride supplements: Y N Has your child ever seen a dentist or dental hygienist: Y N Has s/he had a cleaning in the past 6 months? Y N If yes, Date of last visit:____________________ Dental Office Name:_____________________________________________________ Please circle services your child received at last visit: Cleaning – Fluoride – Sealants – Temp Fillings – Fillings – Other_______________ Please list any dental concerns: ______________________________________________________________________________ BY SIGNING BELOW YOU ARE GIVING PERMISSION FOR YOUR CHILD TO BE SEEN TWO (2) TIMES DURING THIS SCHOOL YEAR (APPROXIMATELY ONCE EVERY 6 MONTHS) This means your child will be automatically added to the schedule for the 6 month out dental hygiene clinic. If your child is participating as a SELF-PAY patient, TPI will contact you before the 6 month out clinic date to send in payment. If no payment is sent to the school, your child will NOT be seen the second time around. I give permission for my child to receive dental hygiene services at school, during school hours. I understand that TPI may release basic information, regarding services provided to benefit my child. I understand that the services provided do not take the place of an exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential and that claims to MaineCare Insurance (if applies to your child) will go directly through TPI per electronic transfer. I agree to notify my child’s school or TPI at (207) 513-1111 of any changes to my child’s medical history.

_________________________________________________ Parent/Guardian Signature

________________________________________________ Printed Name

Date

YOUR CHILD WILL NOT BE DUE FOR ANOTHER CLEANING FOR 6 MONTHS – YOUR CHILD MAY BE SEEN TWO (2) TIMES DURING THIS SCHOOL YEAR