Questions? Call: 855.481.8638

Questions? Call: 855.481.8638

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: William Boyce Thompson School - YONKERS CITY 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. 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.

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.

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
Address *
Apt
City *
State *
Zip Code *

EMERGENCY CONTACT INFORMATION. (IF DIFFERENT FROM PARENT/GUARDIAN INFORMATION PROVIDED)

Emergency Contact Full Name Emergency Contact Relationship to Student Email Address Home Phone*

Insurance Information

Insurance Type*

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.


Important Notice & Consent
I understand and authorize Smile New York Outreach LLC (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, fluoride, sealants, x-rays 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.) I have read the IMPORTANT HEALTH QUESTION above and will report any significant changes in my child’s health to 855-481-8638. I have read the IMPORTANT NOTICE AND CONSENT ON PAGE 2 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 SmileNYOutreach.com.