Dental Sealant Permission Form Language English (US) Spanish (Latin America) Free Dental 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* -Month -DayYearDate Please select your child's school* Please Select May Street Elementary Hood River Valley High Other Your Child's Grade (for the previous school year 2022/2023) Please Select Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 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:* Yes No Fluoride Coating (Varnish) Sealant Silver Fluoride Antiseptic for Teeth Protective Restoration 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 Gender MaleFemaleOtherChoose not to disclose One Community Health staff may contact you if more insurance information is needed. Select Dental Coverage* CapitolAdvantageModa HealthPrivateDon't KnowNo Dental Insurance Subscriber Name First NameLast Name Subscriber Date of Birth -Month -DayYearDate My child is taking... (Please list any medications) 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: Parent/Guardian Name* First NameLast Name Parent/Guardian Phone Number* Please enter a valid phone number. 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 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: Phone Number Please enter a valid phone number. Email example@example.com 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) SaveSubmit Should be Empty:
