Download Children`s Dental Clinic of Jackson County

Children’s Dental Clinic of Jackson County
Dear Parent or Guardian;
Welcome to the Children’s Dental Clinic! We are happy to help your children with their dental needs.
The clinic is designed strictly for school-aged children of low-income families who do not have
dental coverage. The funds for operation of the clinic come from various organizations, such as
United Way, Cities of Medford and Ashland, the Walker Fund of the Oregon Community Foundation,
and Medford Kiwanis. We also rely heavily on contributions from our patient’s families, so
please make a donation in whatever amount you feel you can afford each time your child has
an appointment. Any contribution will help keep our doors open!
In order to be successful in providing quality dental care for your children, there are a few things
we expect from our families…

First and most important, you must keep your scheduled appointments. If you must cancel,
we require a minimum of 24 hours notice for cancellation of an appointment. Should you miss
one appointment, or fail to give 24 hours notice, a $25 deposit is required to reschedule.
This deposit will be returned to you if no more appointments are missed. However, should
you fail another appointment, the deposit will be forfeited and an additional $25 deposit will
be required to schedule another appointment. If you fail 2 appointments, your family will be
dismissed from the clinic. Exceptions may be made at the discretion of the clinic director.

Your child must be on time for scheduled appointments. Tardiness may delay much needed
treatment for your child. If you are late for your scheduled appointment, it will be
considered a failed appointment, and you will be required to pay the $25 deposit to
reschedule.

Patients must brush their teeth before each appointment. We provide disposable
toothbrushes at the reception desk, in case your children were unable to brush at home.

We expect to see improvement in oral hygiene (brushing and flossing) during the course of
treatment. Failure to practice good home care may result in dismissal from our clinic. Our
goal is to educate your children in preventing future decay, and our efforts are wasted if
your children are not “doing their part” in prevention. The clinic staff is rewarded when
they see your child making an effort to prevent decay.

The dentists and hygienists volunteer their time to provide quality dental care for your
child. Please remember to thank them for their donation of time and talents.
Thank you for your “team effort” toward good dental health for your child!
I have read and understand the above requirements.
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Parent’s signature
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Date