PSMD Consent and Health Form

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CHILD’S FULL NAME *

First

Last

DOB *

AGE *

SEX *

NAME OF SCHOOL *

TEACHER *

GRADE *

ROOM *

PATIENT ADDRESS *

CITY / ZIP *

PATIENT PHONE *

INSURED’S DOB (Parent/Guardian) *

Checkboxes *

Rheumatic Fever
Heart Disease
Asthma
Epilepsy
Diabetes
Hay Fever
Cancer
Seizure Disorder
Cerebral Palsy
Hepatitis
Heart Murmur
Kidney or Liver Disease
Tuberculosis
Profuse Bleeding
Bladder
Latex Allergies
None

Other (or please list any conditions/allergies *

IF FURTHER TREATMENT IS NEEDED, YOU WILL RECEIVE A CALL FROM SMILES OF TOMORROW TO OBTAIN CONSENT FOR TREATMENT AT A LATER DATE AT YOUR CHILD’S SCHOOL YES, I give my permission for my child to receive: Fillings (white fillings), Extractions, Pulpotomies and local anesthesia if needed. I am the patient or the responsible party for the listed patient. I hereby authorize Portable Smiles Mobile and SOT to provide the dental treatment described. I authorize Portable Smiles Mobile and Smiles of Tomorrow to access my dental records and findings. I authorize Portable Smiles Mobile and SOT to bill on my behalf, and to use Medicaid (or other insurance)/Delta Dental insurance information for billing purposes. By signing this document, the patient, parent, authorized representative and/or guardian further acknowledges that they understand that treatment obtaining duplicate services at a mobile dental facility may affect benefits that he or she receives from private insurance, a state or federal program, or other third-party provider of dental benefits. * *

YES

BY SIGNING YES TO THIS FORM, I UNDERSTAND THAT: HIPPA COMPLIANCE: PROTECTED HEALTH INFORMATION MAY BE DISCLOSED OR USED FOR TREATMENT, INSURANCE,OR HEALTHCARE OPERATIONS *

YES

EMPLOYER *

IDENTIFICATION# ON CARD or SS# *

POLICY# *

PARENT/PATIENT’S SIGNATURE *

Patient will be seen again in 6 months for follow up service

DATE *

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There is NEVER A COST to the school or parents. Children enrolled in medicaid\Delta Dental, all kids & MI children are covered at 100%, and we can also bill private insurance. Parents must provide coverage information on the consent forms.

Preventative dental service is recommended every 6 months, so we coordinate our return visit every 6-months. Thank you for partnering with portable Mobile Smiles to serve our community & our wonderful children. We commend your recognition of the importance of school-based medical programs for low-income families. This not only boosts student participation, but also provides an opportunity to promote the school and its faculty by highlighting your commitment to being a positive force in your community.

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