{"id":455,"date":"2025-12-18T04:23:43","date_gmt":"2025-12-18T04:23:43","guid":{"rendered":"https:\/\/southernpeachdental.com\/?page_id=455"},"modified":"2026-02-17T11:34:30","modified_gmt":"2026-02-17T16:34:30","slug":"studentform","status":"publish","type":"page","link":"https:\/\/southernpeachdental.com\/es\/studentform\/","title":{"rendered":"Formulario dental para estudiantes en la escuela"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"455\" class=\"elementor elementor-455\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3695fc6 e-flex e-con-boxed e-con e-parent\" data-id=\"3695fc6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-af8820c elementor-widget elementor-widget-heading\" data-id=\"af8820c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">In-School Student Dental Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e08c941 e-flex e-con-boxed e-con e-parent\" data-id=\"e08c941\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-27f75f8 elementor-widget elementor-widget-wpforms\" data-id=\"27f75f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-440\"><form id=\"wpforms-form-440\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"440\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/455\" data-token=\"dd2df8bf0f5d5e977090284cf3294006\" data-token-time=\"1779901664\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-440-field_59-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_59\">Grade <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-440-field_59\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][59]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Head Start\"  class=\"choice-15 depth-1\"  >Head Start<\/option><option value=\"Pre-K\"  class=\"choice-1 depth-1\"  >Pre-K<\/option><option value=\"Kindergarden\"  class=\"choice-2 depth-1\"  >Kindergarden<\/option><option value=\"1st Grade\"  class=\"choice-3 depth-1\"  >1st Grade<\/option><option value=\"2nd Grade\"  class=\"choice-4 depth-1\"  >2nd Grade<\/option><option value=\"3rd Grade\"  class=\"choice-5 depth-1\"  >3rd Grade<\/option><option value=\"4th Grade\"  class=\"choice-6 depth-1\"  >4th Grade<\/option><option value=\"5th Grade\"  class=\"choice-7 depth-1\"  >5th Grade<\/option><option value=\"6th Grade\"  class=\"choice-8 depth-1\"  >6th Grade<\/option><option value=\"7th Grade\"  class=\"choice-9 depth-1\"  >7th Grade<\/option><option value=\"8th Grade\"  class=\"choice-10 depth-1\"  >8th Grade<\/option><option value=\"9th Grade\"  class=\"choice-11 depth-1\"  >9th Grade<\/option><option value=\"10th Grade\"  class=\"choice-12 depth-1\"  >10th Grade<\/option><option value=\"11th Grade\"  class=\"choice-13 depth-1\"  >11th Grade<\/option><option value=\"12th Grade\"  class=\"choice-14 depth-1\"  >12th Grade<\/option><\/select><\/div><div id=\"wpforms-440-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_4\">Teacher Name<\/label><input type=\"text\" id=\"wpforms-440-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-440-field_4-error\" ><\/div><div id=\"wpforms-440-field_47-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_47\">School \/ Center Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-440-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Adamson Middle School\"  class=\"choice-1 depth-1\"  >Adamson Middle School<\/option><option value=\"Anderson-Livsey Elementary School\"  class=\"choice-30 depth-1\"  >Anderson-Livsey Elementary School<\/option><option value=\"Babb Middle School\"  class=\"choice-2 depth-1\"  >Babb Middle School<\/option><option value=\"Baker County Schools\"  class=\"choice-29 depth-1\"  >Baker County Schools<\/option><option value=\"Charles R. Drew High School\"  class=\"choice-3 depth-1\"  >Charles R. Drew High School<\/option><option value=\"Eddie White Middle Academy\"  class=\"choice-4 depth-1\"  >Eddie White Middle Academy<\/option><option value=\"Elite Scholars Academy School\"  class=\"choice-5 depth-1\"  >Elite Scholars Academy School<\/option><option value=\"Forest Park High School\"  class=\"choice-6 depth-1\"  >Forest Park High School<\/option><option value=\"Forest Park Middle School\"  class=\"choice-7 depth-1\"  >Forest Park Middle School<\/option><option value=\"Jonesboro High School\"  class=\"choice-16 depth-1\"  >Jonesboro High School<\/option><option value=\"Jonesboro Middle School\"  class=\"choice-15 depth-1\"  >Jonesboro Middle School<\/option><option value=\"Kendrick Middle School\"  class=\"choice-14 depth-1\"  >Kendrick Middle School<\/option><option value=\"Lovejoy High School\"  class=\"choice-13 depth-1\"  >Lovejoy High School<\/option><option value=\"M.D. Roberts Middle School of the Arts\"  class=\"choice-12 depth-1\"  >M.D. Roberts Middle School of the Arts<\/option><option value=\"Martha Ellen Stilwell School for the Performing Arts\"  class=\"choice-11 depth-1\"  >Martha Ellen Stilwell School for the Performing Arts<\/option><option value=\"Morrow High School\"  class=\"choice-21 depth-1\"  >Morrow High School<\/option><option value=\"Morrow Middle School\"  class=\"choice-20 depth-1\"  >Morrow Middle School<\/option><option value=\"Mount Zion High School (Jonesboro)\"  class=\"choice-19 depth-1\"  >Mount Zion High School (Jonesboro)<\/option><option value=\"Mundy&#039;s Mill High School\"  class=\"choice-18 depth-1\"  >Mundy's Mill High School<\/option><option value=\"Mundy&#039;s Mill Middle School\"  class=\"choice-17 depth-1\"  >Mundy's Mill Middle School<\/option><option value=\"New Vision Academy - Head Start\"  class=\"choice-32 depth-1\"  >New Vision Academy - Head Start<\/option><option value=\"North Clayton High School\"  class=\"choice-10 depth-1\"  >North Clayton High School<\/option><option value=\"North Clayton Middle School\"  class=\"choice-27 depth-1\"  >North Clayton Middle School<\/option><option value=\"Perry Career Academy\"  class=\"choice-26 depth-1\"  >Perry Career Academy<\/option><option value=\"Pointe South Middle School\"  class=\"choice-25 depth-1\"  >Pointe South Middle School<\/option><option value=\"Rex Mill Middle School\"  class=\"choice-24 depth-1\"  >Rex Mill Middle School<\/option><option value=\"Riverdale High School\"  class=\"choice-23 depth-1\"  >Riverdale High School<\/option><option value=\"Riverdale Middle School\"  class=\"choice-22 depth-1\"  >Riverdale Middle School<\/option><option value=\"Sequoyah Middle School\"  class=\"choice-9 depth-1\"  >Sequoyah Middle School<\/option><option value=\"Not Listed\"  class=\"choice-31 depth-1\"  >Not Listed<\/option><\/select><\/div><div id=\"wpforms-440-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Students Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-440-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-440-field_0-error\" required><label for=\"wpforms-440-field_0\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-440-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-440-field_0-last-error\" required><label for=\"wpforms-440-field_0-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-440-field_60-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label\">Students Birth Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][60][date][m]\" id=\"wpforms-440-field_60-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][60][date][d]\" id=\"wpforms-440-field_60-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][60][date][y]\" id=\"wpforms-440-field_60-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-440-field_25-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_25\">Students Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-440-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><\/select><\/div><div id=\"wpforms-440-field_12-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Parent\/Guardian Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-440-field_12\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][12][first]\" aria-errormessage=\"wpforms-440-field_12-error\" required><label for=\"wpforms-440-field_12\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-440-field_12-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][12][last]\" aria-errormessage=\"wpforms-440-field_12-last-error\" required><label for=\"wpforms-440-field_12-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-440-field_53-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_53\">Parent\/Guardian Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-440-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" spellcheck=\"false\" aria-errormessage=\"wpforms-440-field_53-error\" required><\/div><div id=\"wpforms-440-field_51-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_51\">Parent\/Guardian Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-440-field_51\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][51]\" aria-label=\"Parent\/Guardian Phone\" aria-errormessage=\"wpforms-440-field_51-error\" required><\/div><div id=\"wpforms-440-field_52-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_52\">Additional Phone <\/label><input type=\"tel\" id=\"wpforms-440-field_52\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][52]\" aria-label=\"Additional Phone \" aria-errormessage=\"wpforms-440-field_52-error\" ><\/div><div id=\"wpforms-440-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_27\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-440-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-440-field_27-error\" required><\/div><div id=\"wpforms-440-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_28\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-440-field_28\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-440-field_28-error\" required><\/div><div id=\"wpforms-440-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_29\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-440-field_29\" class=\"wpforms-field-medium wpforms-field-required wpforms-limit-characters-enabled\" data-form-id=\"440\" data-field-id=\"29\" data-text-limit=\"2\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-440-field_29-error\" maxlength=\"2\" required><\/div>\t\t<div id=\"wpforms-440-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-440-field_1\" >Phone Practies in-school<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-440-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-440-field_44-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_44\">Zip Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-440-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" step=\"any\" aria-errormessage=\"wpforms-440-field_44-error\" required><\/div><div id=\"wpforms-440-field_31-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_31\">Insurance Type<\/label><select id=\"wpforms-440-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\"><option value=\"Medicaid\/Peachcare\"  class=\"choice-1 depth-1\"  >Medicaid\/Peachcare<\/option><option value=\"Private Insurance\"  class=\"choice-2 depth-1\"  >Private Insurance<\/option><option value=\"No Insurance\"  class=\"choice-3 depth-1\"  >No Insurance<\/option><\/select><\/div><div id=\"wpforms-440-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_32\">Medicaid \/ Peachcare ID  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-440-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-440-field_32-error\" required><\/div><div id=\"wpforms-440-field_37-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_37\">Use space to provide additional details of your child&#039;s health, including current medical treatment. <\/label><textarea id=\"wpforms-440-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-440-field_37-error\" ><\/textarea><\/div><div id=\"wpforms-440-field_57-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_57\">Other significant past illnesses, alcohol and tobacco use (including smokeless). List current medications and premedication for if needed for dental treatment. <\/label><textarea id=\"wpforms-440-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-440-field_57-error\" ><\/textarea><\/div><div id=\"wpforms-440-field_38-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">Medical History Information<\/legend><ul id=\"wpforms-440-field_38\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_1\" name=\"wpforms[fields][38]\" value=\"AIDS\/HIV Positive\" aria-errormessage=\"wpforms-440-field_38_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_1\">AIDS\/HIV Positive<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_2\" name=\"wpforms[fields][38]\" value=\"Asthma\" aria-errormessage=\"wpforms-440-field_38_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_2\">Asthma<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_3\" name=\"wpforms[fields][38]\" value=\"Cancer\" aria-errormessage=\"wpforms-440-field_38_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_3\">Cancer<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_4\" name=\"wpforms[fields][38]\" value=\"Contagious Disease\" aria-errormessage=\"wpforms-440-field_38_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_4\">Contagious Disease<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_5\" name=\"wpforms[fields][38]\" value=\"Diabetes\" aria-errormessage=\"wpforms-440-field_38_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_5\">Diabetes<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_6\" name=\"wpforms[fields][38]\" value=\"Heart Condition\" aria-errormessage=\"wpforms-440-field_38_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_6\">Heart Condition<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_7\" name=\"wpforms[fields][38]\" value=\"Hemophilia\/Bleeding Problems\" aria-errormessage=\"wpforms-440-field_38_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_7\">Hemophilia\/Bleeding Problems<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_8\" name=\"wpforms[fields][38]\" value=\"Kidney Disease\" aria-errormessage=\"wpforms-440-field_38_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_8\">Kidney Disease<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_9\" name=\"wpforms[fields][38]\" value=\"Liver Disease\" aria-errormessage=\"wpforms-440-field_38_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_9\">Liver Disease<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_10\" name=\"wpforms[fields][38]\" value=\"Rheumatic\/Scarlet Fever\" aria-errormessage=\"wpforms-440-field_38_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_10\">Rheumatic\/Scarlet Fever<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_11\" name=\"wpforms[fields][38]\" value=\"Seizures\" aria-errormessage=\"wpforms-440-field_38_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_11\">Seizures<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_12\" name=\"wpforms[fields][38]\" value=\"Pregnant\" aria-errormessage=\"wpforms-440-field_38_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_12\">Pregnant<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_13\" name=\"wpforms[fields][38]\" value=\"Sickle Cell Anemia\" aria-errormessage=\"wpforms-440-field_38_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_13\">Sickle Cell Anemia<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_14\" name=\"wpforms[fields][38]\" value=\"Tuberculosis\" aria-errormessage=\"wpforms-440-field_38_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_14\">Tuberculosis<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_15\" name=\"wpforms[fields][38]\" value=\"Wheel Chair Access\" aria-errormessage=\"wpforms-440-field_38_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_15\">Wheel Chair Access<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"radio\" id=\"wpforms-440-field_38_16\" name=\"wpforms[fields][38]\" value=\"Allergies to Medications\" aria-errormessage=\"wpforms-440-field_38_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_38_16\">Allergies to Medications<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-440-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-field-readonly\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_58\">If your child already has a dentist you should keep going to that dentist. <\/label><input type=\"text\" id=\"wpforms-440-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-440-field_58-error\" ><\/div><div id=\"wpforms-440-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_39\">Name and Phone # of Child&#039;s Physician<\/label><input type=\"text\" id=\"wpforms-440-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-440-field_39-error\" ><\/div><div id=\"wpforms-440-field_64-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Important Notice &amp; Consent <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-440-field_64\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-440-field_64_1\" name=\"wpforms[fields][64][]\" value=\"I&#039;ve Read The Statement And I Agree\" aria-errormessage=\"wpforms-440-field_64_1-error\" aria-describedby=\"wpforms-440-field_64-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_64_1\">I've Read The Statement And I Agree<\/label><\/li><\/ul><div id=\"wpforms-440-field_64-description\" class=\"wpforms-field-description\">I understand that a licensed dental hygienist will be providing preventive dental services directly on-site at the school, operating under general supervision of a licensed dentist as permitted by Georgia law (O.C.G.A. \u00a7 43-11-74(h)). This includes procedures such as oral prophylaxis (cleanings), application of topical fluoride, and sealants, all performed with prior written parental\/guardian consent for each student.<\/div><\/fieldset><\/div><div id=\"wpforms-440-field_41-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Important Notice &amp; Consent <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-440-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-440-field_41_1\" name=\"wpforms[fields][41][]\" value=\"I&#039;ve Read The Statement And I Agree\" aria-errormessage=\"wpforms-440-field_41_1-error\" aria-describedby=\"wpforms-440-field_41-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_41_1\">I've Read The Statement And I Agree<\/label><\/li><\/ul><div id=\"wpforms-440-field_41-description\" class=\"wpforms-field-description\">I understand and authorize Southern Peach Dental, PC (Provider) and its affiliated dental professionals to provide the following services for the above-named child for whom I am the custodial parent or legal guardian: oral evaluation &amp; oral hygiene instruction, teeth cleaning, fluoride treatment, silver diamine fluoride (SDF), x-rays, and dental sealants. I understand that there are risks to dental treatment including swelling or pain that may occur or allergic reaction. (For additional information regarding the risks of treatment and treatment alternatives, please call the number below.) I authorize &amp; direct Provider to bill &amp; collect payment from any Medicaid, insurance, or other payer. If I have private dental insurance, I will be billed for &amp; agree to pay any deductibles and\/or co-pays. Unless I have made pre-arrangements to attend, and am there at the time of service, services will be provided without my presence. I have received the Notice of Privacy Practices attached to this form and consent to the release of my child\u2019s medical record information as described therein. We may send you text messages about the school dental program. Message and\/or data fees may be charged by your wireless service provider; to discontinue texts, reply \u201cSTOP\u201d to any message received from us. You also agree to receive pre-recorded and\/or auto-dialed telephone calls relating to the school dental program at the land-line and\/or mobile telephone numbers provided on this consent form. This signed consent authorizes my child\u2019s initial dental visit and future visits. I may withdraw this consent at any time in writing to the address below.<\/div><\/fieldset><\/div><div id=\"wpforms-440-field_63-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">Notice of Privacy Practies <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-440-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-440-field_63_1\" name=\"wpforms[fields][63][]\" value=\"I&#039;ve Read The Statement And I Agree\" aria-errormessage=\"wpforms-440-field_63_1-error\" aria-describedby=\"wpforms-440-field_63-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-440-field_63_1\">I've Read The Statement And I Agree<\/label><\/li><\/ul><div id=\"wpforms-440-field_63-description\" class=\"wpforms-field-description\">\tNOTICE OF PRIVACY PRACTICES\t\nTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.\nOUR LEGAL DUTY\nWe are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect December 1st, 2025, and will remain in effect until we replace it. \nWe reserve the right to change our privacy practices and the terms of this Notice at any time, provided such charges are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.\nYou may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. \n\nUSES AND DISCLOSURES OF HEALTH INFORMATION\nYour child\u2019s health information and the rights associated with that health information also rest with the \u201cpersonal representative\u201d of that individual, generally the parent or legal guardian. \nWe use and disclose health information for treatment, payment, and healthcare operations. For example:\nTreatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to your child. \nPayment: We may use and disclose your health information to obtain payment for services we provide to you. \nHealthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. \nYour Authorization: In addition to your use for your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. \nTo Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. \nPersons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment and or experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. \nMarketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. \nRequired by Law: We may use or disclose your health information when we are required to do so by law. \nAbuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. \nNational Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances. \nAppointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, text-messages, postcards, or letters). \n\nPATIENT RIGHTS\nAccess: You have the right to look at or get copies of your health information, with limited exceptions. Contact us using the information listed at the end of this Notice for a full explanation of time and fees involved. \nDisclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, health care operations and certain other activities, for the last 6 years, but not before December 1st, 2025. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. \nRestriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency). \nAmendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. \nElectronic Notice: If you receive the Notice on our Website or by electronic mail (e-mail), you are entitled to receive this Notice in written form. \n\n QUESTIONS AND COMPLAINTS\nIf you want more information about our privacy practices or have questions or concerns, please contact us. \nIf you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. \nWe support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint. \n<\/div><\/fieldset><\/div><div id=\"wpforms-440-field_56-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_56\">Signature of Parent\/Guardian <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-440-field_56\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][56]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-440-field_56-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-440-field_56-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-440-field_42-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-440-field_42\">How did you hear about the in-school dental program? <\/label><select id=\"wpforms-440-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Permission Form From School\"  class=\"choice-1 depth-1\"  >Permission Form From School<\/option><option value=\"Teacher\"  class=\"choice-2 depth-1\"  >Teacher<\/option><option value=\"School Nurse\/Health Office\"  class=\"choice-3 depth-1\"  >School Nurse\/Health Office<\/option><option value=\"Principal\/Admin\"  class=\"choice-4 depth-1\"  >Principal\/Admin<\/option><option value=\"Email From School\"  class=\"choice-5 depth-1\"  >Email From School<\/option><option value=\"Text Message From School\"  class=\"choice-6 depth-1\"  >Text Message From School<\/option><option value=\"Poster At School\"  class=\"choice-7 depth-1\"  >Poster At School<\/option><option value=\"Social Media\"  class=\"choice-8 depth-1\"  >Social Media<\/option><option value=\"School&#039;s Electronic Sign\"  class=\"choice-9 depth-1\"  >School's Electronic Sign<\/option><option value=\"School Website\"  class=\"choice-10 depth-1\"  >School Website<\/option><option value=\"School Event or Info Table\"  class=\"choice-11 depth-1\"  >School Event or Info Table<\/option><option value=\"Flyer\/Letter From School\"  class=\"choice-12 depth-1\"  >Flyer\/Letter From School<\/option><option value=\"School Newsletter\"  class=\"choice-13 depth-1\"  >School Newsletter<\/option><option value=\"School&#039;s Parent Portal\"  class=\"choice-14 depth-1\"  >School's Parent Portal<\/option><option value=\"Robocall From School\"  class=\"choice-15 depth-1\"  >Robocall From School<\/option><option value=\"Video From School\"  class=\"choice-16 depth-1\"  >Video From School<\/option><\/select><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-440-field_1-container { position: 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