School Dental Hygiene Program Permission Form - Thornton Academy


Tooth Protectors Inc.
___ Added to Scheduling Form
School Dental Hygiene Program Permission Form
Patient Consent & Medical/Dental History
P.O. Box 314 Lewiston, Maine 04243
Office (207) 513-1111
If your child is being seen
SIX (6) MONTHS by a dental provider other than Tooth Protectors at school, for either
an exam by a dentist, dental cleaning and fillings (if needed) do not fill out this form as she/he does not qualify for the service.
Please COMPLETE ONE FORM per child – incomplete forms will result in your child NOT being seen
School Name:______________________________________________ Teacher/Grade:_________________________________
Child’s Full Name:____________________________________________________________________ Date of Birth: _____/______/__________ Male / Female
Mailing Address:__________________________________________________________Town:_____________________________ Zip Code:________________
Home Phone:____________________________
Cell: __________________________ Email:___________________________________________________
DENTAL SERVICES: Must Choose 1 Service Below
Full Dental Cleaning, Review, Fluoride & Sealants
– Only if your child has not had a cleaning within the past 6 months.(
sealants if recommended)
– This is NOT a Dental Cleaning- this is an Educational Review of proper brushing, flossing & fluoride treatment
(sealants placed on those with insurance if
PAYMENT METHOD: Must Choose 1 Form of Payment Below*
Accepted Dental Insurance: MaineCare, CIGNA, Anthem, UMR, United if your dental insurance is NOT listed, please contact Tooth Protectors to see if accepted
(Accepted ins.
is subject to change without notice)
*If you have Dental Insurance AND MaineCare, please provide information for both. The Dental Insurance must be billed first and denied before MaineCare will reimburse for services.
Accepted Payment Options: Cash, Check, Money Order, and Credit Cards
(MC, Visa, Discover, American Express - note there is a $3.00 service fee)
- ID Number for Child: ______________________________________________
- Ins. Company Name:_________________________________ Policy Holders Full Name:_____________________________
Policy Holders Date of Birth:________________ Group #____________________________ Policy/Subscriber ID:___________________________
Check #_________
Money Order/Bank Check
Credit Card
(I have called TPI to make this payment)
To pay by Cash, Check, or Money Order, attach the exact amount to this COMPLETED permission form and return form & payment to the School
Please make checks/MO payable to: TPI or Tooth Protectors Inc. - There will be a $25.00 fee for insufficient funds
Please make out a Separate Check for Each Child being seen and write your child’s Full Name in the Memo Line of your check
To pay by Credit Card, call our office at 207-513-1111 to make payment and return this COMPLETED permission form to the School
___ My child is age 12 or Under, for
Full dental cleaning, Educational Review, Fluoride treatment & 4 sealants
(if recommended)
___ My child is age 13 to 21, for
- Full dental cleaning, Educational Review, Fluoride treatment & 4 sealants
(if recommended)
$25.00 -
___ My child is age 1-21, for
Educational Review of proper brushing, flossing and fluoride treatment.
(Does NOT INCLUDE a Dental Cleaning or Sealants)
Please list dental concerns you may have:_________________________________________________________________________________________________
Please list any Medical Conditions/Allergies your child has:___________________________________________________________________________________
List ALL Medications:___________________________________________________________________________Physicians Name:________________________
Has your child ever needed Antibiotics for dental treatment? Y N if yes, please take the same precautions prior to treatment at school.
Has your child ever seen a Dentist? Y
Does your child take Fluoride Supplements? Y
Do you have Town/City Drinking Water? Y
Has he/she had a cleaning in the past 6 months? Y
If yes, was it at school? Y
Patient was last seen
(month & year)
Patient last seen by
(if was NOT last seen at school):______________________________________________________________________________________________________
Please circle the services your child received during Last Visit: Cleaning—Fluoride—Sealants—Temp Fillings—Fillings—Exam—X-Rays—Other:______________
Dental Services you DO NOT want your child to receive from Tooth Protectors Inc. please list:_____________________________________________________
. (
I give permission for my child to receive dental hygiene services TWO (2) TIMES DURING THIS SCHOOL YEAR
,if my child's school is able to offer it two times this school year.) I understand
a reminder from the school and/or TPI that my child will be automatically added to the dental clinic list to be seen prior to the 2
dental clinic date.
that I will receive
It is
my responsibility to contact/notify either TPI (207) 513-1111 or my child's school prior to the spring dental clinic date to make any changes regarding my child’s medical/dental history or to remove
them from the spring dental clinic list. I understand dental services are being provided by a registered, licensed dental hygienist with Public Health Status (PHS) associated with Tooth Protectors Inc.
(TPI), at school, during school hours. I have entered my child’s information on this permission/consent form accurately and truthfully and understand that it is my responsibility to report/remember my
child’s date of dental service. I am also responsible to report this date when needed for current/future dental treatment and cannot hold TPI responsible if the information is not accurate/truthful on this
form regarding current and/or previous treatment/appointments with other dental office locations. I agree to notify my child’s school and/or TPI at (207) 513-1111 of ANY changes to my child's
medical/dental history or of a dental home. I give permission for TPI to release patient and dental service information to benefit my child. I understand that services provided do not take the place of a
complete exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential and that claims to insurance (if applies to your child) will go through TPI per electronic
transfer or mail. Services not paid for by my insurance are my responsibility. I understand that if I have listed insurance information for my child & he/she does NOT have dental coverage at the time
services are provided, and/or received the same services by another dental provider within 6 months and I did not divulged this above, than I assume all responsibility for payment of services received
and understand that I will receive a bill from Tooth Protectors Inc.
_____________________________________________ ______________________________________________ ________________
Parent/Guardian Signature
Parent/Guardian Printed Name
TPI School Permission Form 2014/2015


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