School-Based Dental Consent Form- English

Dear Parent/Guardian:

Community Health Center of Snohomish County’s Dental team will be offering Smile Checks (dental screenings), and/or
sealants and fluoride at your student’s school at no cost to you. A dentist will examine your student's teeth and determine
which teeth need to be sealed. Sealants and fluoride help prevent cavities and are recommended by the American Dental
Association. Please fully complete and sign this form so we can provide high-quality healthcare services for your student. If
you have more than one student, please complete one form per child. Your school will announce upcoming dates when we will
be onsite. This consent will remain active for the school year unless expressly revoked in writing.

Student's School

Student's Teacher:

Student's Grade

Student's Name:

First NameMiddle InitialLast Name

Student's Date of Birth:

Date

Age

Gender

Other:

Address

Street Address

Street Address Line 2

City

Postal / 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. Smile Checks (visual screening) will be performed in the Fall and Spring and are required to receive sealants or fluoride. Sealants will be provided based on patient age and findings of the screening.

Dental Exam (Required for service below)

Fluoride Varnish

Sealants

**Sealants are not Placed on Preschool students

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 student or family will be charged for services or receive a bill.

Please select the student's type of insurance:

Provider One number (If applicable):

Insurance ID #:

Insurance Group #:

Subscriber Name:

Subscriber DOB:

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 a Smile Check (Dental Screening) and the marked treatment(s) above:

Parent/Guardian Full Name:

First NameLast Name

Parent/Guardian 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

Demographics: