To Nurture and Respect

Parent Permission Form

Lumina Dental HealthCare’s dental team will be coming to our school to provide preventive dental services to your children, which may include x-rays, exams, dental sealants and cleanings. In order for the dentist to see your child you must fill out the information below and sign.



Payment Options:








CHILD’S MEDICAL HISTORY

Child’s Information: When was child’s last dental visit?

IS ANTIBIOTIC PRE-MEDICATION REQUIRED?

CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD *

(To select multiple options, please hold the Ctrl key of Keyboard and select the multiple options.)




Parent/Guardian Information:


Siblings attending same school (Full names of brothers/sisters)

In order to be seen by the dentist, a separate permission form is required for each child.

I am a custodial parent or legal guardian of the minor child named above and give permission for my child to participate in this program and for the dentist and his/her staff to share the information obtained during the examination only with those people necessary to complete billing and/or to meet the requirements of the state and the local school district. A copy of the Notice of Privacy Practices is available to me.