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Pollard Dental Screening Program Permission Slip Student Name ________________________________________________ Date of Birth________________ Teacher___________________________________________________ Grade ______________________ Parent or Guardian _______________________________________Email____________________________ Home Phone ______________________________ Cell Phone_____________________________________ Child’s Dentist _____________________________________________ Last Visit ______________________ Reason for last visit _______________________________________________________________________ How did he or she react ____________________________________________________________________ 1. I hereby give do not give permission for my child to have the free dental screening. 2. Please check additional services you would like your child to receive: Free Fluoride Varnish Free Decay-stopping fluoride (applied twice during the school year to help stop a cavity from getting bigger and to make it feel better. You can tell it worked if the cavity becomes hard and black. Limited to molars.) 3. Does your child have a congenital heart defect requiring pre-medication with antibiotics before dental treatment? Yes -Explain___________________________________________________ No 4. Does your child have any allergies? Yes -Explain___________________________ No 5. Has your child ever had any serious health problems? Yes - Explain No ________________________________________________________________________________________ 6. Is your child unable to receive dental treatment in a dental office? Yes No If unable to do so, please check all that apply. Can’t find a dentist who accepts our insurance Cost Transportation Fear Can’t afford insurance co-pays Can’t take time off from work Other_________________________________________________________________________________ 7. Does your child have Medical Insurance? Yes No 8. Does your child have Dental insurance? Yes No If yes, which kind of dental insurance ? Private insurance Medicaid I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment and fluoride if requested. I understand this screening is only a very simple evaluation and does not take the place of a thorough dental examination. I understand my child’s dental assessment for treatment may be shared with the school nurse and in the event of a referral for treatment, with the dental office treating your child. I understand that a copy of Pollard Dental Screening Program Privacy Practices can be obtained by contacting Plaistow Pediatric Dentistry and Orthodontics at (603) 974-1150 or visiting the website at www.Plaistowsmiles.com and clicking on the school screening program link. __________________________________________________________ Signature of Parent or Guardian __________________________ Date