Smiles to Go Dental Form

Smiles to Go Dental Form
Name*

First NameMiddle NameLast Name
Gender Identity*

MaleFemaleOther
Patient's Birthday*

MonthDayYear
Date
Date of last dental exam*

MonthDayYear
Date
Name of child's school building *
Name of child's teacher*
Grade level*
Parent/Guardian Name*
Phone Number of Parent/Guardian*
Please enter a valid phone number.
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian email address*
example@example.com
Emergency contact name*

First NameLast Name
Emergency contact phone number*
Please enter a valid phone number.
Child's Primary Physician*
Physician phone number*
Please enter a valid phone number.
May we contact the physician if needed?*

YesNo
Ethnicity*

Hispanic/LatinoNot Hispanic/LatinoDecline
Race*

WhiteBlack/African AmericanAmerican Indian or Alaska NativeNative HawaiianAsianOther Pacific IslanderMore than one raceDecline
What is the insurance coverage of the patient?*

MedicaidPrivate Dental InsuranceUninsured (a payment of $100 must be paid prior to child being seen. If child is being seen at school, payment must be sent to JCHD prior to appt)
8 Digit MO HealthNet ID#*
Dental Insurance Company*
Member ID#*
Group #*
Insured Adult*
Relationship to child*
Insured Employer*
Insured Adult Date of Birth*

MonthDayYear
Date
Insured SS#*
Insurance Company Phone Number*
Please enter a valid phone number.
Accepted form of payment. Please check one.*

CashMoney Order (payable to JCHD)Personal Check (payable to JCHD) *must include copy of driver's license or birthdate and SSN of responsible person
Optional: Upload photo of FRONT and BACK of insurance card

Cancelof
Does your child have or has your child ever had any of the following (check all that apply):*

ADD/ADHDLatex AllergyHearing, Speech, Communication problemsArtificial JointAllergies OtherAsthmaDiabetesHIV/AIDSHospitalization in last 5 yearsFainting/SeizuresRheumatic FeverSeasonal AllergyHeart ConditionHepatitis A, B, or CAutism Spectrum DisorderNONE
Is antibiotic pre-medication required for dental treatment?*

YesNo
If you checked any of the above, please explain
My child is currently taking these medications
Anything else we should know about your child?
We value you as our patient and need your cooperation with keeping appointments so that we can provide your care. Missing or cancelling an appointment with less than 24 hours’ notice means we are unable to fill this appointment timewith another patient who desperately needs care.

Our policy requires:
- Timely Cancellations: If you need to cancel or reschedule your appointment, you must give us at least 24 hours’ notice.Cancellations made with less than 24 hours’ notice will be considered a missed appointment.
- On Time Arrivals: If you are more than 15 minutes late to your appointment, we may need to reschedule you foranother time.
- Compliance: Patients are only allowed three missed appointments. After the third missed appointment, you will beplaced on “same day” only status. If you have any additional appointments scheduled those appointments will becancelled.
Many patients use Jefferson County Health Department Dental Practice’s services. Your help in keeping yourappointments enables us to provide better and timelier care for all our patients.
Signature*

Clear
DateTime
Please read carefully and sign. By signing this Health History & Consent form, you are giving consent to the Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic to provide any dental services and/or treatment deemed necessary for your child.

I, as the parent or guardian, authorize the Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic or individual designated by Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic to act for me in any emergency, accident, or illness.

I give consent for my child to receive dental services. To the best of my knowledge, the medical history questions have been answered correctly and accurately. I allow my child to receive local anesthetic (numbing of the teeth), preventative & restorative dental treatment (including, but not limited to fillings, extractions, sealants, cleaning, and fluoride), and to be photographed while at the clinic.

CONSENT FOR TELEHEALTH SERVICES

Dental services at JCHD may be provided through the use of electronic and/or digital communications, or teledentistry.Participation in teledentistry services is voluntary, but refusal to utilize these services may limit available services.

I authorize JCHD to bill my insurance company and receive payment for dental services performed. I acknowledge that I am able to exercise my rights under HIPAA of 1996 to access JCHD’s privacy policy by visiting their website at www.jeffcohealth.org and that all information shared here is confidential. I understand that my child’s oral health results will be shared with the school nurse for the purposes of data collection and care coordination. I understand this consent is valid for 1 year from the date of signature.
Parent Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
DateTime*
I hereby consent to release for possible publication my child's name and/or photo(s) and /or video images taken by any authorized Jefferson County Health Department (JCHD) employee. This may include television, newspaper, magazine article, social media sites (Facebook, Twitter, Instagram, YouTube ,etc.) and/or JCHD publications (newsletters, flyers, brochures, website, etc.).I also agree to allow the publication or broadcast of my name in connection with any photo(s) and/or video images taken, and I understand that I will not receive numeration for my voluntary participation or future use of any photo(s)and/or images of me. I understand that photos and /or videos for the media and/or World Wide Web may be used in publications and /or Web sites outside of JCHD control. I understand that I may revoke this authorization at any time by notifying the person or organization providing the information in writing.*
Parent/Guardian Signature*

Clear
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