Combined Smile Check and Sealant Consent (MS and HS)

Student's School:

Student's Grade:

Dear Parent/Guardian:

Community Health Center of Snohomish County's School-Based team will be offering dental screenings and limited dental treatment at your student's school at no cost to you. A dentist will examine your student's teeth and determine what type of treatment is needed. Please fully complete and sign this form so we can provide high-quality healthcare services for your student. This consent will remain active for the school year unless expressly revoked in writing.

Student's Name

First NameMiddle Name InitialLast Name

Date of Birth

Date

Age

Gender

Other

Address

Street Address Line 2

City

Zip Code

Consent to complete:

Check the "Yes" box for treatments you are giving permission for, and the "No" box for those that you do NOT give permission for.

Dental Exam (x1-2 a year)

X-rays (x1-2 a year)

Cleaning/Scaling (x1-2 a year)

Sealants (x1 a year)

Fluoride Varnish (x1-2 a year)

Additional Consent for Treatment (ex: fillings) will be sent home with your student

Please provide the following information

All students are eligible. Service is provided at no cost to your family. Insurance will be billed if applicable, but no charges will be extended to any families.

Please select the student's type of insurance:

Student's 9 digit Provider One number or SSN:

Insurance ID #:

Insurance Group #:

Please contact your school nurse with any questions regarding your student receiving dental services at school.

By my signature, I am giving CHC of Snohomish County permission for my student to receive the marked treatment(s) above:

Parent/Guardian Full Name:

Parent/Guardian Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Signature:

Today's Date:

Date

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have rights to privacy regarding my protected health information (dental & health records I understand CHC of Snohomish County may contact me about appointment reminders, treatment options, test results or other health related benefits and services via phone call, text message, email, or voicemail. I hereby acknowledge I have access to CHC's Notice of Privacy Practices before signing the consent at any time by contacting: Community Health Center of Snohomish County, 8609 Evergreen Way, Everett, WA 98208, or phone (425) 789-3700 or by going to our website at: www.chcsno.org.

School-Based Dental Consent Form

School-Based Dental Consent Form

School-Based Dental Consent Form

Demographics:

Health