Download Dental Screening Program Permission Slip

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