Please fill out this form to register your child for a dental screening, fluoride and sealants at their school.
Child's Birth Date
Cell Phone Number
Alternate Phone Number
Child's School Name
Race/Ethnicity (Check all that apply)
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
My child receives (Check all that apply)
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:
Has your child been to the dentist before?
If yes to above question, where has the child been seen and when was the last dental visit?
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
Medical Assistance (MA)
Prepaid Medical Assistance Program (PMAP)
My child has no dental insurance
Please enter your insurance ID number
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This form was created inside of Open Door Health Center.