Smiles of Tomorrow, PC Dental Parental Consent Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.School *Grade *Teacher *Child's Legal Full Name, *FirstMiddleLastDate of Birth *Age *Email *Multiple Choice *MaleFemaleAddress *Preferred Language *EnglishSpanishI give my permission for my child to receive: Fillings (amalgam/composite) Extractions, Pulpotomies and local anesthesia. I understand that the preventative provider will share any necessary Information with Smiles of Tomorrow, PC. *YesPrinted Parent Name *Date *I am the porent or legal guardian of the above named child and I authorize Smiles of Tomorrow to provide dental services, bill and collect from my dental insurance company. I understand that obtaining duplicate services from Smiles of Tomorrow & your dental home may affect your dental benefits. I will hold harmless Smiles of Tomorrow, its staff. Employees, officers or volunteers of my child's school/child care center. I understand that the name address, telephone number of the provider of services is listed on the oral Health assessment given to my child upon completion of services; and will use that information to make contact if any questions should arise. *Yes***THIS CONSENT WILL BE VALID FOR THE 12 MONTH PERIOD OF THIS PROGRAM** Is your child allergic to anything? If yes, what? *Is your child taking any medication? If yes, what? *Has your child had a history of *heart diseaseasthmahay feverhepatitiscancerdiabetesseizure disorderkidney or liver diseaserheumatic fevercerebral palsytuberculosisprofuse bleedingbladdergrowth problemsnoneor any other medical conditions? If yes, what? * Does your child have learning or emotional impairments? If yes, what? *Name of Insurance *No payment is required from you for this program. However, Medicald/Healthy Kids Dental/MIChild and other dental insurance carriers will be billed to help cover the cost of this program. Please fill out the Insurance Information in detail below. Thank you. Insured Name *Private Insurance *Name of Insurance *Insured Name *FirstLastEmployer *Medicald # *Policy, ID# or SS# *Employer Phone# Your child’s personal information will be kept confidential and will not be shared with any person who is not directly involved in the care of your child as part of the Health Insurance Portability and Accountability Act (HIPAA). Dental services may be obtained at the patient’s dental home rather than with the mobile dental facility and obtaining duplicate services may affect Insurance benefits that he or she receives from private insurance, a state or federal program, or other third-party provider of dental benefits. Submit Spread the love
