Questions? Call: 800.409.2563

Questions? Call: 800.409.2563

Student Permission Form

School: Charnock Elementary School - LAUSD West Ed Center  Wrong School?

School Information

Taking care of your child’s teeth is important to keep them healthy. And, having your child seen by the in-school dentist is both easy & convenient for you.

Big Smiles will check your child's mouth & teeth, as well as provide a cleaning, x-rays as necessary, fluoride treatment and apply sealants, as needed. Additional care, such as fillings, may also be provided. A dental report card will be sent home with your child. By completing this form, your child will receive dental care at school about every 6 months.

Zip Code *
School*
If you don’t see your child’s school listed, please call one of our Care Coordinators at 800-409-2563.

Child Information

Thank you for choosing the in-school dentist to take care of your child’s teeth. Simply complete this easy step-by-step permission form.

By doing so, Big Smiles will regularly check your child's mouth & teeth, as well as provide a cleaning, x-rays as necessary, fluoride treatment and apply sealants, as needed. Additional care, such as fillings, may also be provided. A dental report card will be sent home with your child. By completing this, the dentist will be able to see your child for their initial visit as well as all follow-up visits.

Child First Name *
Child Last Name*
Birth Date *
Gender *
Grade *
Teacher Name

Parent/Guardian Information

*
Your First Name*
Your Last Name *
Email Address *
Telephone *
Alternate Telephone
Address *
Apt
City *
State *
Zip Code *

EMERGENCY CONTACT INFORMATION. (IF DIFFERENT FROM PARENT/GUARDIAN INFORMATION PROVIDED)

Emergency Contact Full Name Email Address Home Phone Home Phone

Insurance Information

Insurance Type*

Medical History Information

DOES YOUR CHILD HAVE ANY PAST OR PRESENT MEDICAL CONDITIONS, DISABILITIES, BEHAVIOR OR OTHER PROBLEMS? PLEASE CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD AND EXPLAIN IN THE SPACE PROVIDED. IF NO CONDITIONS APPLY, LEAVE BLANK.

Asthma

Allergies to foods

Behavior problems

Bleeding Disorders

Breathing Problems

Contagious diseases (including COVID-19)

Dental Problems

Diabetes

Heart Condition

Immune Disorders

Kidney disease

Liver disease

Seizures

Allergies to medications

Other

OTHER/EXPLAIN List Current Medications

List Current Dental Concerns
Important Notice & Consent
I understand and authorize Marn DDS Dental Practice P.C. (Provider), its affiliated dentists and dental hygienists, and externs from UCLA and UCSF Schools of Dentistry under dentist supervision, to provide dental services at school to the above named child for whom I am the custodial parent or legal guardian. Dental services include an exam, cleaning, fluoride, sealants, Preventive Resin Restoration, x-rays and the application of Silver Diamine Fluoride as needed. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color. SEE PAGE 2 FOR DETAILS.) I also authorize any other dental work such as fillings, extractions of problem baby teeth, performing a pulpotomy (baby tooth nerve treatment), numbing the mouth and teeth, and other procedures as needed. I have read the IMPORTANT HEALTH QUESTION above and will report any significant changes in my child’s health to 855-481-8639. I have read the IMPORTANT NOTICE AND CONSENT ON PAGE 2 OF THIS FORM and understand and agree to its terms.
I've read the statement and I agree.
How did you hear about the in-school dental program? (Check all that apply.)





For more information, please visit BigSmilesDental.com.