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  • English (US)
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  • Healthy Smiles Patient Registration

  • PROGRAM PARTICIPATION

    Healthy Smiles will be on site providing teledentistry services through our Smiles X-Press program. All students will be receiving dental health education. Additionally, Smiles X-Press provides the following services: dental exams, x-rays, fluoride varnish, sealants and temporary fillings on a case by case basis to qualifying Medi-Cal students. Students with private insurance are encouraged to see their private dental provider. During the visit, qualified dental staff will review the child's health history. They may provide x-rays, intra-oral photographs and a dental exam. The exam information is reviewed by our dentist at an offsite location and a treatment plan will be created within 24-48 hours from the time of the visit
  • Patient Information

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  • MEDICAL HISTORY

  • INSURANCE

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  • CONSENT

  • I authorize for my child to have the following services without my being present:(Click here for a description of each service) 

     

  • I request that all dental benefits, if any, or other amounts which may payable to me or on my behalf for services rendered to my child, be paid directly to Healthy Smiles for Kids of Orange County (“HSK”), the provider of services. I authorize HSK to release all information necessary to secure payment of benefits. I also authorize and consent to the dental examination and/or treatment of my child. I am aware that by signing below I certify that all information on this form is complete and correct. HSK may verify this information from whatever sources it deems necessary and may provide others with this information to the extent permitted by law. By signing this document, I acknowledge that I have received a copy of Healthy Smiles for Kids of Orange County Patient Bill of Rights and Responsibilities by clicking here

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