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*
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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 :