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

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

3.

DENTAL INSURANCE INFORMATION

CHECK ONE

Medicaid covers 100% of Treatment

Enter Child's ID

Number Here:

4.

CHECK TOTAL CARE OF PREVENTATIVE CARE

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.

Thanks for submitting!