Important Notice & Consent
I understand and authorize S.K. Pesis D.D.S. Big Smiles Maryland, PC or OHIP Lawrence B. Caplin DMD, P.A.(Provider) (Provider) and its affiliated dentists or dental hygienists to provide
the following services to the 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, as well as the application of Silver Diamine Fluoride to treat the progression of tooth decay. I also authorize the dentist to fill any cavities or to place a crown over the tooth, extract
any problem baby teeth, perform a pulpotomy (baby tooth nerve treatment), place space maintainers or perform other dental treatments as needed. I understand that there are risks to dental
treatment including swelling or pain that may occur from the treatment or injection of a local anesthetic, or allergic reaction. (For additional information regarding the risks of treatment and
treatment alternatives, please call the number provided.) I understand that a portion of my child’s dental examination may be performed remotely and that clinical information (such as x-rays)
may be collected and sent electronically to another site for the dentist’s evaluation. I consent to these teledentistry services and understand that while confidentiality protections apply, the
use of third party electronic transmissions may present additional privacy risks. I understand that I have the right to access medical information related to teledentistry services. I authorize
& direct Provider to bill & collect payment from any Medicaid, insurance, or other payer. I authorize my child’s school to make available to Provider and its billing agent my child’s insurance
information in order to bill payer for services. If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co pays. Treatment by the in-school dentist may affect
future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at the time of service, services will be
provided without my presence. I consent to the Provider sending text messages about the school dental program. I acknowledge that text messaging is not a secure form of communication
and presents additional privacy risks. (Message and/or data fees may be charged by your wireless service provider; to discontinue, 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.) I have
received the Notice of Privacy Practices (NPP) attached to this form and consent to the release of my child’s medical record information, including records obtained from other providers, and
any HIV/AIDS, communicable disease, sexually transmitted disease, drug and alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor
and/or administrative service provider and their subcontractors, and if my child is a participant in the Maryland Healthy Smiles program, the primary dentist office with which the Provider
contracts for my child’s school, for use and disclosure relating to my child’s treatment, payment for services and health care operation purposes. This signed consent authorizes my child’s
initial and future dental visits. This permission is valid from the date of signature until my student is no longer a City Schools student, unless I withdraw consent in writing. I may withdraw this
consent at any time in writing.
You Must Read and Agree to the Important Notice & Consent Statement Prior to Submitting
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