Gateway to Oral Health Foundation

IN SCHOOL DENTAL CARE

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

First Name

Last Name

CHOOSE ONE

Male

Female

Student Birthday

Race

School

Teacher

School District

Grade

Room#

Your Name

Relation to Student

Custodial Parent

Legal Guardian

Address

City

State

Zip

Phone

2nd Phone

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

List allergies

Name/Phone# of child's physician

Use space below to provide additional details on your child's health, including currrent medical tereatment, other signicant past illnesses, alcohol & tobacco use (including smokeless). List current medications.

Approx. date of last dental visit.

3.

DENTAL INSURANCE INFORMATION

CHECK ONE

Medicaid covers 100% of Treatment

Child's Insurance Type

CHILD IS UNINSURED

CHILD HAS MEDICAID

CHILD HAS PRIVATE DENTAL INSURANCE

Enter Child's ID

Number Here:

ID#

GROUP#

Name of Plan

Name of Insured Parent

Parent DOB

Parent SSN

Work Phone

Employer

Insurance Phone

4.

CHECK TOTAL CARE OR PREVENTIVE CARE

Select an option

Total Care - Oral hygiene instructions, dental exams, x-rays, cleanings, flouride, sealants, fillings, crowns, baby teeth, root canals, and removal of hopeless teeth

Preventive Care only - Oral hygiene instructions, dental exams, x-rays, cleaning, flouride, and sealants.

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 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

Date

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