IN SCHOOL DENTAL CARE

Please complete, sign, and return to school. Questions? Please call (314) 872-3930

1.

Taking care of your Child's teeth is important to keep them healthy.

TELL US ABOUT YOUR CHILD

Student Name

CHOOSE ONE
Relation to Student

2.

CHILD'S MEDICAL HISTORY

CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD

Notify us of any medical history changes. A thorough complete medical and dental history are important for a proper dental examination and evaluation

Medical Conditions
Medical Conditions Cont.

3.

DENTAL INSURANCE INFORMATION

CHECK ONE

Medicaid covers 100% of Treatment

Enter Child's ID

Number Here:

4.

CHECK TOTAL CARE OF PREVENTATIVE CARE
Select an option

By signing this consent form I give consent to the Gateway to Oral Health Foundation affiliated general dentists to provide dental care to my child at school without my p[presence unless I withdraw this consent. I also authorize and direct Gateway to Oral Health foundation to bill and collect payment from any Medicaid, Insurance, or third party payer that covers the services provided to this patient. I agree to pay any portion of the charges not covered by the insurance. Photographs may also be taken and used as an educational/marketing tool for our program. Once signed, this consent form is valid for the entire school year.

Your Signature

© 2020 by Kids Charity.

Call us:

314-872-3930

Find us: 

2211 Olive Street, St. Louis, Missouri 63103