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: River Ridge Elementary School - River Ridge C U School District 210  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, fluoride treatment and apply sealants, as needed. 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.

EASY & CONVENIENT - A state licensed dentist will regularly check your child’s mouth & teeth, as well as provide a cleaning, X-rays, fluoride treatment and apply sealants, as needed. A dental report card will be sent home with your child. Permission includes initial dental care & follow-up visits.SIGN AND RETURN TO YOUR SCHOOL TODAY!

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.

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 Solomon Pesis DDS, Dental Outreach P.C. (Provider), its affiliated dentists or dental hygienists, to provide dental services at school to the above named child for whom I am the custodial parent or legal guardian, including an exam, cleaning, X-rays. fluoride, sealants 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 BACK FOR DETAILS.) This also gives permission for IDPH quality assurance audits to be performed & providers to return to my child’s school to recheck my child’s sealants. 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 THE BACK 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 MobileDentists.com.