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

EVERY

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

THIS FORM PROVIDES PERMISSION FOR YOUR CHILD TO BE SEEN TWO TIMES DURING THIS

SCHOOL YEAR FOR DENTAL CARE

GENERAL INFORMATION:

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)

Review

____

– This is NOT a Dental Cleaning- this is an Educational Review of proper brushing, flossing & fluoride treatment

(sealants placed on those with insurance if

recommended)

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)

_A

___ MAINECARE INSURANCE

- ID Number for Child: ______________________________________________

______

___ OTHER DENTAL INSURANCE

- Ins. Company Name:_________________________________ Policy Holders Full Name:_____________________________

Policy Holders Date of Birth:________________ Group #____________________________ Policy/Subscriber ID:___________________________

___ SELF PAY

PAYMENT METHOD

Check #_________

Cash

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

$45.00

___ My child is age 12 or Under, for

-

Full dental cleaning, Educational Review, Fluoride treatment & 4 sealants

(if recommended)

$55.00

___ 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)

MEDICAL/DENTAL HISTORY:

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

N

Does your child take Fluoride Supplements? Y

N

Do you have Town/City Drinking Water? Y

N

Has he/she had a cleaning in the past 6 months? Y

N

If yes, was it at school? Y

N

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

nd

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

Date

TPI School Permission Form 2014/2015

62014