PROGRAM BENEFITS CONSENT FOR YOUR CHILD All patients will receive an oral health screening,
______________________________________________
fluoride treatment and oral hygiene instruction by the
(Name of Child)
I give permission for my child to be examined and/or
Most patients will receive all their necessary dental
treated by the dental provider representing Commonwealth
Mobile Oral Health Services (CMOHS), LLC.
Some patients may need to be scheduled for further
I understand that dental treatment may include any or all of
dental treatment and will be referred to a dental
the following: Dental Exam and Diagnosis, X-Rays, Dental Cleaning, Oral Hygiene Instruction, Topical Fluoride Application, Preventive Sealants, Fillings, Other Restorative Dentistry and Recall Visits. Referrals are dependent on the extent of the dental
disease as well as the behavior of the patient.
I give permission for my child to have fillings with the
possible application of local anesthetic xylocaine most commonly called “novocaine”.
Great News!!! Your child can receive the following Informed consent indicates your awareness of
I understand that this consent will stay in effect while my
sufficient information to allow you to make an
child attends this school, or upon retraction of the consent.
informed personal choice concerning the patient’s
DENTAL SERVICES
It is the parent/guardian’s responsibility to inform the dental
dental treatment. Most patients do not encounter any
provider and/or the school nurse of any changes in the
at school
difficulties with their treatment. In rare instances, a
child’s medical history and insurance information.
patient may experience some discomfort or pain. If
the patient indicates any resistance to the dental
I understand that the patient’s health information may be
procedure, we would discontinue the treatment.
used for treatment, payment and health care operations.
If I have dental insurance, I authorize my insurance carrier
The Tell-Show-Do technique is often used to gain the
cooperation and confidence of the dental patient. The
I have read and understand the dental program and I
dental provider explains what they are going to do a
♦ Restorative Dentistry (fillings)
few times, then shows what they are going to do with
instruments on a model. The provider makes every
_____ YES, I give permission for my child to participate in the dental program. (sign below)
♦ Recall Visits (Continuous Care)
effort to be a partner in care with the patient and
family making the dental visit pleasant and
_____ NO, I do not give permission for my child to PLEASE BE SURE TO SIGN LAST Signature of Parent or Legal Representative
CONTACT INFORMATION: Printed Name Relationship to the Child and Date PATIENT INFORMATION INSURANCE INFORMATION MEDICAL INFORMATION Please be sure to complete all sections. Please be sure to complete all sections.
If your child has Mass Health and/or dental insurance,
the insurance company will be billed directly for the
___/___/___/ - ___/___/___/ - ___/___/___/___
MassHealth
Does your child have any allergies?
___/___/___/___/___/___/___/___/___/___/___/___
If yes, please check all that apply: Antibiotics,
Colophonium, Foods, Latex, Penicillin,
____/____/ - ____/____/ - ____/____/____/____
Resins, Medications (list)_______________
Date of Birth (month / day / year)
Other: ________________________________
____/ ____/ ____/- ____/____/-____/____/____/____
Does your child need antibiotics before dental Delta Dental, CMSP or Other
treatment? yes _____ no_____ If yes, please Dental Insurance
explain: ________________________________
Does your child take medications on a routine
basis? yes _____ no_____ If yes, please list:
Does your child have a developmental disability? yes _____ no_____ If yes, please
___/___/___/ - ___/___/___/ - ___/___/___/___
explain: ________________________________
___/___/___/ -___/___/___/ - ___/___/___/___
Subscriber’s Date of Birth (month / day / year)
Has your child ever had any of the following?
Has your child been to the dentist in the past
year? yes _____ no_____ If yes, dentist name: Race: Please check all that apply (Optional)
3 Asian; 4 Native Hawaiian/Pacific Islander
Other: __________________________________
PROGRAM BENEFITS