Tufts community dental program

PROGRAM BENEFITS
CONSENT FOR YOUR CHILD
All patients will receive an oral health screening,
______________________________________________ fluoride treatment and oral hygiene instruction by the (Name of Child)
I give permission for my child to be examined and/or Most patients will receive all their necessary dental
treated by the dental provider representing Commonwealth Mobile Oral Health Services (CMOHS), LLC. Some patients may need to be scheduled for further
I understand that dental treatment may include any or all of dental treatment and will be referred to a dental the following: Dental Exam and Diagnosis,
X-Rays, Dental Cleaning, Oral Hygiene Instruction,
Topical Fluoride Application, Preventive Sealants,
Fillings, Other Restorative Dentistry and Recall Visits.
Referrals are dependent on the extent of the dental
disease as well as the behavior of the patient. I give permission for my child to have fillings with the possible application of local anesthetic xylocaine most commonly called “novocaine”. Great News!!!
Your child can receive the following
Informed consent indicates your awareness of
I understand that this consent will stay in effect while my sufficient information to allow you to make an child attends this school, or upon retraction of the consent. informed personal choice concerning the patient’s DENTAL SERVICES
It is the parent/guardian’s responsibility to inform the dental dental treatment. Most patients do not encounter any provider and/or the school nurse of any changes in the at school
difficulties with their treatment. In rare instances, a child’s medical history and insurance information. patient may experience some discomfort or pain. If the patient indicates any resistance to the dental I understand that the patient’s health information may be procedure, we would discontinue the treatment. used for treatment, payment and health care operations. If I have dental insurance, I authorize my insurance carrier The Tell-Show-Do technique is often used to gain the
cooperation and confidence of the dental patient. The I have read and understand the dental program and I dental provider explains what they are going to do a ♦ Restorative Dentistry (fillings) few times, then shows what they are going to do with instruments on a model. The provider makes every _____ YES, I give permission for my child to
participate in the dental program. (sign below)
♦ Recall Visits (Continuous Care) effort to be a partner in care with the patient and family making the dental visit pleasant and _____ NO, I do not give permission for my child to
PLEASE BE SURE TO SIGN LAST
Signature of Parent or Legal Representative

CONTACT INFORMATION:
Printed Name
Relationship to the Child and Date
PATIENT INFORMATION
INSURANCE INFORMATION
MEDICAL INFORMATION
Please be sure to complete all sections.
Please be sure to complete all sections.
If your child has Mass Health and/or dental insurance, the insurance company will be billed directly for the ___/___/___/ - ___/___/___/ - ___/___/___/___ MassHealth
Does your child have any allergies?
___/___/___/___/___/___/___/___/___/___/___/___ If yes, please check all that apply: Antibiotics,
Colophonium, Foods, Latex, Penicillin, ____/____/ - ____/____/ - ____/____/____/____ Resins, Medications (list)_______________
Date of Birth (month / day / year) Other: ________________________________ ____/ ____/ ____/- ____/____/-____/____/____/____
Does your child need antibiotics before dental
Delta Dental, CMSP or Other
treatment? yes _____ no_____ If yes, please
Dental Insurance
explain: ________________________________ Does your child take medications on a routine
basis? yes _____ no_____ If yes, please list:
Does your child have a developmental
disability? yes _____ no_____ If yes, please
___/___/___/ - ___/___/___/ - ___/___/___/___ explain: ________________________________ ___/___/___/ -___/___/___/ - ___/___/___/___ Subscriber’s Date of Birth (month / day / year) Has your child ever had any of the following? Has your child been to the dentist in the past year? yes _____ no_____ If yes, dentist name:
Race: Please check all that apply (Optional)
3 Asian; 4 Native Hawaiian/Pacific Islander Other: __________________________________

Source: http://www.attleboroschools.com/docs/Dental_Application___English.pdf