Free Dental School Services

Free Dental School Services

Permission Form
One Community Health will be onsite during the school year to provide FREE dental services. Please submit this form to take advantage of these FREE services.
Your Child's Name*

First NameMiddle InitialLast Name
Child's Date of Birth*

MonthDayYear
Date
Please select your child's school*
Your Child's Grade
Teacher's Name (K-5th grade only)
I want my child to have a dental screening and receive FREE dental services if needed:*

YesNoI'm not sure. Please contact me with more information.
The following FREE services may be offered to your child if needed. Please select the services you would like your child to receive through this program if eligible:*

Fluoride Coating (Varnish)SealantSilver FluorideAntiseptic for TeethProtective Restoration
To learn more about these services, please visit this link.
Gender

MaleFemaleOtherChoose not to disclose
Select Dental Coverage*

CapitolAdvantageModa HealthPrivateDon't KnowNo Dental Insurance
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber ID
ID as stated on your insurance card
One Community Health staff may contact you about insurance if more information is needed.
My child is taking the following medications: (if no medications, write "none")*
Please mark below any allergies your child has:

NoneIodineShellfish (i.e., shrimp, crab)Other (Please describe)
My child has (select all that apply):

Had surgery in the past 2 yearsHigh blood pressureEpilepsyAsthmaDiabetesNone of the aboveOther health concern (Please describe)
My Child is Allergic to: (if no allergies, write "none")*
Parent/Guardian Name*

First NameLast Name
Thank you for your interest in our school dental program, we have already completed dental services at your child's school. Please visit us next school year to sign your child up for school dental services!
Would you like us to contact you when the dental program restarts next school year?

Yes, please call meYes, please text meYes, please email meNo thanks
Thank you for your interest in our school dental program, please fill out either your name or email and we'll get in touch with more information:
Parent/Guardian Phone Number*
Please enter a valid phone number.
Email
example@example.com
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
Your signature indicates that you have been informed of the risks and benefits of treatment and that you consent to the treatment indicated above. You also acknowledge that you have received the Notice of Privacy Practices.
Parent/Guardian Signature*

Clear
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 regularly sees a dentistMy child's dentist will provide these servicesOther (Please Describe)
Admin Comments
Should be Empty: