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. 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, a state licensed dentist 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.
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Select Your Insurance Type Medicaid/Peachcare Private Insurance No Insurance
Medical History Information Use space below to provide additional details on your child’s health, including current medical treatment, other significant past illnesses, alcohol and tobacco use (including smokeless).
List current medications and premedication if needed for dental treatment.
If Yes, explain below. IF NO, LEAVE BLANK.
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NAME AND PHONE # OF CHILD’S PHYSICIAN
Important Notice & Consent
I understand and authorize Georgia Dental Outreach, PC (Provider) and its affiliated dentists to provide the following services for the above-named child for whom I am the custodial parent or legal guardian : dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays, dental sealants and silver diamine fluoride treatment, if needed. I authorize the dentist to fill any cavities or to place a stainless steel crown over the tooth if needed. I authorize Provider to extract any problem baby teeth, provide a baby root canal (removal of the nerves inside the tooth), place space maintainers or perform any other dental work as needed. I understand that there are risks to dental treatment including swelling or pain that may occur from the injection of a local anesthetic or allergic reaction. (For additional information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize & direct Provider to bill & collect payment from any Medicaid, insurance, or other payer. If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co-pays. Unless I have made pre-arrangements to attend, and am there at the time of service, services will be provided without my presence. I have received the Notice of Privacy Practices attached to this form and consent to the release of my child’s medical record information as described therein. We may send you text messages about the school dental program. Message and/or data fees may be charged by your wireless service provider; to discontinue texts, reply “STOP” to any message received from us. You also agree to receive pre-recorded and/or auto-dialed telephone calls relating to the school dental program at the land-line and/or mobile telephone numbers provided on this consent form. This signed consent authorizes my child’s initial dental visit and future visits. I may withdraw this consent at any time in writing to the address below.
You Must Read and Agree to the Important Notice & Consent Statement Prior to Submitting
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How did you hear about the in-school dental program? (Check all that apply.)
