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 School Track: Classroom : Teacher : Grade : 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. 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 Parent/Guardian Information: Name* Relationship * Phone Number (Cell)* Phone Number (Home) Address * City ZIP Email Address * 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 :
