Taking care of your Child's teeth is important to keep them healthy.
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
Medicaid covers 100% of Treatment
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.
