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*

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?

CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD *

(To select multiple options, please hold the Ctrl key of Keyboard and select the multiple options.)

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 :