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. 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. 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.
Select Male Female
Select Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
Teacher Name
Parent/Guardian Information
Select Mother Father Guardian
Select Grandparent Aunt or Uncle Other
Alternate Telephone
Apt
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhoda Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Emergency Contact Full Name
Emergency Contact Relationship to Student
Email Address
Home Phone *
Insurance Information
Select Your Insurance Type Medicaid Private Insurance No Insurance
Medical History Information Does your child have any medical condition that may complicate dental treatment? This may include heart issues, breathing problems, seizures, allergies, bleeding problems, communicable diseases, immune disorders, etc.
If Yes, explain below. IF NO, LEAVE BLANK.
RequiredFieldValidator
Important Notice & Consent
I consent for my child to receive oral health care services provided by the State-licensed health professionals of Smile New York Outreach LLC as part of the school oral health program approved by the
New York State Department of Health for as long as my child is enrolled at school. I understand and authorize Smile New York Outreach LLC (Provider) and its affiliated dentists and 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 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 and collect payment from any Medicaid, insurance, or other payor, if any, as well as to release my child’s information to any responsible payor and/or administrative
service provider and their subcontractors for use and disclosure relating to my child’s treatment, payment for services and health care operation purposes. (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 on the top of this form. This signed consent authorizes my
child’s initial and future dental visits. I may withdraw this consent at any time in writing
You Must Read and Agree to the Important Notice & Consent Statement Prior to Submitting
The birth date or zip code you entered on the previous page is incorrect. Please go back to the previous page to check what you entered and try again.
How did you hear about the in-school dental program? (Check all that apply.)
