Free Dental Sealants

We appreciate you taking the time to complete this form. This completed form helps us to continue to offer dental services in our community.

I want my child to be screened and receive sealants if needed: *

Yes No I'm not sure. Please contact me with more information.

I also want to strengthen my children's teeth with Fluoride Varnish

Yes No

Do any of the following apply to your child? This will help us better understand the oral health of children in our community.

My child already has sealants My child regularly sees a dentist My child's dentist will provide sealants Other (Please Describe)

Parent/Guardian Name *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Your child's name *

First Name Middle Initial Last Name

Child's Date of Birth *

Date

Please select your child's school *

Thank you for your interest, but we have already visited this school for the 2021/2022 school year. Looks for us next year!

Grade *

At this time we are only screening first through fifth graders at your child's elementary school. We look forward to enrolling your child in this program next year.

Teacher's Name *

My Child is taking... (Please List Medications)

My Child is Allergic to:

My child has (select all that apply):

Had Surgery High Blood Pressure Epilepsy Asthma Diabetes Other (Please Describe)

Select Dental Coverage *

Capital Advantage Moda Health Private Don't Know No Dental Insurance

Notice of Privacy Practices

You have the right to:

Get a copy of your paper or electronic record
Correct your paper or electronic record
Request confidential communication
Ask us to limit the information we share
Get a copy of the detailed privacy notice upon request
Choose someone to act for you
File a complaint if you believe your rights have been violated

Note: All requested for changes, limitations, corrections, and complaints must be made in writing. OCH staff can assist you in this process.

You have a choice in how much OCH can share your health information as we:

Tell family and friends about your condition, treatment, and care
Provide Mental Health Services for you
Raise funds. We may contact you for fundraising efforts but you can tell us not to contact you again.

OCH may use and share your information as we:

Treat you
Run our organizations
Bill for Services
Help with public health and safety
comply with the law, court orders, and respond to legal actions
Address workers' compensation, law enforcement, and governmental request

By signing this permission slip you are acknowledging that you have received the notice of privacy practice. If your child has an urgent treatment need, the school nurse will be notified of follow-up care.

Parent/Guardian Signature *

Clear