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.

Child’s First Name *

Child’s Last Name*

Gender
MaleFemale

Child’s Birth date*
Day12345678910111213141516171819202122232425262728293031 MonthJanFebMarAprMayJunJulAugSepOctNovDec Year201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935

When was child’s last dental visit?
0-6 Months6-12 Months1-2 YearsMore than 2 yearsNever

School

Track:

Classroom :

Teacher :

Grade :

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Payment Options:

Medi-Cal – Children enrolled in this program receive the services at no cost.

Medi-Cal ID # *

(Must be provided if eligible for Medi-Cal)

Private Insurance - Most private insurance companies cover 100% of these services

Name of Dental Insurance

Phone #
Member ID or Group #

Insured’s Name

Birthdate

Insured’s SS#

Employer

For children without Medi-Cal or private insurance we are happy to provide an exam, teeth cleaning and fluoride treatment for the special fee of $57.00. Payment by check is due when this form is returned.

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CHILD’S MEDICAL HISTORY

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

IS ANTIBIOTIC PRE-MEDICATION REQUIRED? SelectYesNo

CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD *

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

No known medical problemRecent dental problemSickle cell anemiaLatex allergy                                       Anemia/faintingAllergy to medication/otherLiver problem/hepatitis    Asthma/wheezingEpilepsy/seizuresBehavioral problem                                Kidney problemRheumatic feverHIV/AIDSCommunicable diseases   CancerDiabetesTuberculosisBleeding problem                                               Heart problem/murmur

List Allergies

Additional details of child’s health, including current medical treatment,
significant past illnesses, current medications

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Parent/Guardian Information:

Name*

Relationship *

Phone Number (Cell)*

Phone Number (Home)

Address *

City

ZIP

Email Address *

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

Grade

Name

Grade

Name

Grade

Name

Grade

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.

PARENT/GUARDIAN SIGNATURE * :

Date :