Questions? Call: 800.409.2563

Questions? Call: 800.409.2563

STUDENT PERMISSION FORM FOR IN-SCHOOL DENTAL CARE

Your child can get dental care at school! There is no cost for children covered by Medicaid. No need to take time off work and students miss less class time, too. Sign up today!

School: Shaw Middle School - SPOKANE SCHOOL DISTRICT  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.

A state licensed dentist 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

ToothSavers is a mobile oral health program that provides safe and painless preventive dental services in Washington State schools during school hours. Tooth decay is the #1 chronic disease among children. If left untreated, cavities can lead to other infections and diseases. The CDC (Centers for Disease Control and Prevention) reports that dental sealants reduce tooth decay by up to 80%

ToothSavers offers:
Oral health screenings: a visual screening to check the health of the teeth/mouth and detect any dental problems or emergencies.
Dental sealants: A protective tooth-colored shield that is placed on teeth in the back of the mouth, where children most often get cavities.
Fluoride varnish: A dental strengthening gel that is applied to the teeth to add a layer of protection against cavities.
Silver diamine fluoride (SDF): A non-invasive liquid that, when placed over suspicious cavities, can stop the decay process, strengthen the tooth, and may prevent the need for invasive treatments such as a filling or crown

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
*
Apt
City *
State *
Zip Code *

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.

Allergy to silver

Asthma

Autism spectrum

Behavior problems

Diabetes

Heart Murmur

Heart problems

Hepatitis

Seizures

Sensory disorder

Other

OTHER/EXPLAIN


Important Notice & Consent
This form serves as informed consent. By completing and signing this form, you consent to ToothSavers providers rendering the oral health services listed above for your child at their school. There are two visits per school year. You may opt-out at any time by providing written notice. Do NOT fill out form unless you want your child to be seen by ToothSavers.
FAQ
Q. What if my child already has a dentist?
A. That’s great! Your child can also see ToothSavers. Our visual screenings do not interfere with dental exams. However, ToothSavers is not a substitute for routine dental visits. If your child does not have a dentist, visit DentistLink.org or call them at 844-888-5465.
Q. Does insurance cover these services?
A. Yes. Apple Health/Medicaid/Molina pays 100% of our fees. We also accept Delta Dental of WA, Metlife, Lincoln, and others. Please call to see what private insurance we can bill. We offer reduced rates and accept credit card payments if you don’t have insurance.
Q. What is the cost to me?
A. Apple Health/Medicaid – NO COST
Private Insurance – NO COST or CO-PAYMENT
Cash Fees: Visual Screening-$14, Fluoride Varnish-$34, Dental Sealant-$32 per tooth, Silver Diamine Fluoride-$5 per tooth
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How did you hear about the in-school dental program? (Check all that apply.)

For more information, please visit MobileDentists.com.