School Screenings
Please fill out this form to register your child for a dental screening, fluoride and sealants at their school.
* Required
Child Name
*
Your answer
Child's Birth Date
*
MM
/
DD
/
YYYY
Child's Gender
*
Male
Female
Required
Parent/Guardian Name
*
Your answer
Cell Phone Number
*
Your answer
Alternate Phone Number
Your answer
Child's School Name
*
Your answer
Child's Grade
*
Your answer
Child's Teacher
*
Your answer
Race/Ethnicity (Check all that apply)
White
Black/African American
Asian
Hispanic
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Other
My child receives (Check all that apply)
Free lunch
Reduced lunch
Special Education services
Permission for Open Door Health Center to provide services
Please select what services you would like your child to participate in
Application of fluoride varnish
*
Yes, I give permission for the application fluoride varnish treatment.
No, I do not give permission for the application of fluoride varnish treatment.
Application of dental sealants
*
Yes, I give permission for dental sealant treatment
No, I do not give permission for dental sealant treatment
Application of Silver Diamine Fluoride (SDF)
*
Yes, I give permission for silver diamine fluoride (SDF)
No, I do not give permission for silver diamine fluoride (SDF)
Photo and video release
*
Yes, I give permission to use photos or videos of our staff serving your child
No, I do not give permission to use photos or videos of our staff serving your child
Notice of privacy practices
You have privacy rights under the Minnesota Government Data Practices Act and the Federal Health Insurance Portability and Accountability Act (HIPAA). These laws protect your privacy, but also lets us give information about you to others if the law requires it. We will use or disclose your personal health information only for the purpose for your treatment, payment of services provided to you, or for healthcare operations.
Your name and responses will be recorded when you submit this form and they will sere as your virtual signature and acknowledgement of our privacy practices and consent for services you have indicated above. Please type name below:
*
Your answer
Has your child been to the dentist before?
Yes
No
Clear selection
If yes to above question, where has the child been seen and when was the last dental visit?
Your answer
Payment from Minnesota Health Care and other insurances help to cover the cost of this sealant program. If your child is covered by a Minnesota Health Care Program, please check the name of his or her insurance program and fill in the ID number.
There is currently no cost to participate in the sealant program
Please check the name of the insurance
MinnesotaCare
UCare
Blue Plus
Medical Assistance (MA)
Prepaid Medical Assistance Program (PMAP)
Other
My child has no dental insurance
Please enter your insurance ID number
Your answer
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