Healthy Smiles Consent and Registration Form

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
Consent To Participate in the program *

YES, I WISH FOR MY CHILD TO PARTICIPATE IN THE SMILES X-PRESS PROGRAM (CONTINUE FILLING OUT FORM) NO, I DO NOT WISH FOR MY CHILD TO PARTICIPATE IN THE SMILES X-PRESS PROGRAM (DO NOT CONTINUE FILLING OUT FORM
Patient Information
Child's last name: *
Child's first name: *
Date of Birth: *

Month Day Year
Date
Sex: *

Male Female
Address *

Home Address

Street Address Line 2

City & Zip
Parent phone #: *
Text? *

Yes No
Parent/legal guardian's name: *
Email *
example@example.com
Parent's preferred language: *
School: *
Teacher: *
Grade: *
List other children enrolled in this school *
If none, put "none"
Race: *

African American Asian/Pacific Islander Hispanic Native American/Alaskan Indian White Other
MEDICAL HISTORY
Drug allergies: *

Yes No
Explain:
Food allergies:

Yes No
Explain:
Other allergies:

Yes
Explain:
Heart condition/heart murmur: *

Yes No
Diagnosis:
Cardiologist's name:
Cardiologist's phone number:
if applicable
Please select if your child has any of the following *

Acid Reflux AIDS/HIV Asthma Autism Bleeding Issue Cancer Cerebral Palsy Developmental Delay Diabetes Down Syndrome Epilepsy/Seizures Dry Mouth Hemophilia Liver Disease Herpes Joint Replacement Kidney Disease Muscular Dystrophy Thyroid Problems Tuberculosis None
Other medical conditions not listed above?
Please explain: If none, put "none"
Medications? *
Please explain:If none, put "none"
Any hospitalizations / surgeries? *

Yes No
Explain:
Pediatrician name:
Pediatrician phone number:
Is the child scheduled for a dental cleaning in the next 3 months? *

Yes No
Any questions or concerns about your child's teeth?
Please explain:
INSURANCE
Does your child have medical insurance? *

Yes No
What type of dental insurance does your child have? *

Medi/Denti-Cal PPO None
Medi Cal #(BIC):
Subscriber ID# (PPO):
Subscriber's complete name (PPO):
PPO insurance company:
Subscriber date of birth:

Month Day Year
Date
CONSENT
I authorize for my child to have the following services without my being present:(Click here for a description of each service)
Preventative dental care: exam, X-Rays, cleaning and polish

Yes No
Flouride varnish: reduces the risk of cavities and helps strengthen enamel

Yes No
Dental sealants: protective coating applied to grooves of the molars

Yes No
Release and exchange of information

Yes No
Photos for media

Yes No
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
Parent/Legal Guardian Signature:

Clear
Relationship to Child:
Today's Date:

Month Day Year
Date
Newsletter

Yes, I want to join the Smiles Notification team!
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Healthy Smiles Patient Registration

PROGRAM PARTICIPATION

Patient Information

MEDICAL HISTORY

INSURANCE

CONSENT