Douglas County Dental Clinic Friendly Smiles Program

 

Parent/Guardian Consent Form

(Please complete both sides in blue or black ink)

 

Dear Parent/Guardian,

 

A preventive dental hygiene program is being offered by Douglas County Dental Clinic (DCDC) for your school. A licensed dentist and/or a specially licensed dental hygienist will be providing the services listed below. All procedures are painless and preventive in nature. Complete both sides of this form and return it to your school. For additional information contact Brianne Koester, Program Coordinator, at (785) 312-7770 ext. 206 or brianne@dcdclinic.org.

 

Dental Screening – A standardized screening is performed to assess the state of your child’s oral health. If areas of concern are identified (such as possible tooth decay, gum disease or soft tissue lesions) the hygienist will attempt to contact you and work with you to have your child seen by a dentist.

 

Oral Hygiene Education – Your child will be given a new toothbrush and shown effective ways to keep their teeth clean and cavity-free. We will also review dietary impact on oral health (snacks, drinks, etc.)

 

Dental Exam and X-rays – Diagnostic services include the oral examination and selected radiographs needed to assess the oral health, diagnose oral disease, and develop an adequate treatment plan for the patient’s oral health.

 

Dental Cleaning – Hard and soft deposits containing bacteria will be removed from your child’s teeth by use of hand instruments and a rubber cup polisher. This will help to prevent or allow healing of any infection that may be present in your child’s gum (soft) tissue and reduce the chance of new decay occurring on the teeth.

 

Fluoride Varnish – A protective coating will be applied to the teeth to help strengthen and protect them from decay. There are no limitations for eating or drinking after this application (no “wait” period). This is most effective when applied immediately after a dental cleaning.

 

Dental Sealants – A white plastic material will be applied to the chewing surfaces of the back teeth (molars) to help prevent cavities. This does not include any “drilling” and is reversible.

 

 

I hereby give permission for my child, _______________________________________, to receive any dental treatment considered necessary as described above. I understand I will be given a written report to notify me of what services he/she received. My child’s health information may be mutually shared with his or her school nurse, school administrators, teachers and others as needed to complete his/her dental care. This also allows us to share any dental/oral health information attained through this program with the dentist and the dentist(s) of your choice. No information gathered through this program will be used for any purpose other than is considered necessary for your child’s oral health. If you do not wish for your child to receive any of the above listed services, please list them here: _________________________________________________________

 

 

This consent is in effect for one calendar year from the date of your signature.

 

 

Parent/Guardian Name (please print legibly) ________________________________________________________________

 

 

Parent/Guardian Signature _______________________________________________________________ Date __________________