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Sign Up Your Student

Grade *

Teacher Name

School Name *

Patient / Student Name *

Date of birth *

Parent / Guardian First Name *

Parent / Guardian Last Name *

Parent / Guardian Email *

Parent / Guardian Phone *

Street Address *

Country *

State *

City *

Postal Code *

Insurance Type *

If commercial insurance, please provide policy holder name, policy holders DOB subscriber ID, and insurance company phone number, *

Policy Holder Number

Policy Holders DOB

Subscriber ID

Insurance company phone number

Use space to provide additional details of your child's health, including current medical treatment.

Other significant past illnesses, alcohol and tobacco use (including smokeless). List current medications and premedication for if needed for dental treatment.

Medical History Information

AIDS/HIV Positive

Asthma

Cancer

Contagious Disease

Diabetes

Heart Condition

Hemophilia/Bleeding Problems

Kidney Disease

Liver Disease

Rheumatic/Scarlet Fever

Seizures

Pregnant

Sickle Cell Anemia

Tuberculosis

Wheel Chair Access

Allergies to Medications

*Note If your child already has a dentist you should keep going to that dentist.

Name and Phone # of Child's Physician

Important Notice & Consent

Important Notice & Consent *

I've Read The Statement And I Agree

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. § 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.

I've Read The Statement And I Agree

I understand and consent to dental services being provided through teledentistry. I understand that teledentistry involves the use of electronic communications and is not the same as an in-person clinical examination performed in a dental office. The authorizing dentist will not be physically present during the teledentistry encounter. I understand that if an in-person examination or treatment is recommended or needed, I will be referred to an in-person dentist for further evaluation. I have been informed of the risks, benefits, and alternatives to teledentistry, including the option to receive care in person instead. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. I voluntarily consent to teledentistry services.

Signature of Parent/Guardian *

Clear

How did you hear about the in-school dental program?

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