School Dental Health Program
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2School Dental Health Program
Dental Consent Form
Your child’s school has been selected to participate in the Kansas School Dental Health Program. Dental Professionals
will be offering services in your child’s school such as sealants, fluoride varnish, and/or cleanings. While any child is
eligible to participate, these services are intended for those children without a regular or family dentist and who would not
otherwise receive this care due to limited family income or lack of insurance coverage.
School Name____________________________________________ City_____________________________________
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Student Name_____________________________
Date of Birth___________ Age_____
Gender:
Male
Female
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White
American Indian/Alaska Native
Other
Asian
Race/
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Native Hawaiian/Pacific Islander
Black/African American
Hispanic
Ethnicity
(check all that apply)
Parent/Guardian Name____________________________________
Daytime phone____________________________
Parent/Guardian Address_________________________________ City_______________ State____ Zip_____________
The State of Kansas and the Dental Professionals administering this program are dedicated to improving your child’s
dental health by offering outreach dental services. After your child is treated, you will receive a report stating what
services were provided along with a dental referral if needed.
The information from my child’s participation in this special event will be utilized anonymously for statistical purposes and
information that identifies my child or family will never be disclosed in any form or publication.
If offered, please check all services that your child may receive:
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Sealants (if indicated)
Fluoride Treatment
Dental Cleaning
I give CHC/SEK permission to provide preventative dental services for my child and to collect payment from Medicaid,
Health Wave or other dental insurance provider that covers my child’s care. I understand that there is no out-of-pocket
cost to me or to my child’s school.
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Medicaid # ___________________________________
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Health Wave # ________________________________
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Is your child covered under private dental insurance? (not Medicaid or Health Wave)
No
Yes
If yes, please provide insurance name and policy number_______________________________
Parent/Guardian Signature________________________________________________ Date_____________________
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