Permission Form for School Based Dental Health Program

Rogue Community Health
2024-2025 School Year

Permission to Participate in District #9, #59, & #91 School Based Dental Health Program
School:*
Teacher:*
Grade:*
Student Name:*

First NameLast Name
Nickname:
Birth Date:*

MonthDayYear
Gender:*

MaleFemale
Address:*

Address

Street Address Line 2

CityState / Province

Zip Code
Primary Phone:*
Parent/Guardian's Name*
Please check YES or NO for each service you consent to for your child:

*CHILD MUST HAVE A DENTAL SCREENING TO RECEIVE FLUORIDE AND/OR SEALANTS
Oral Screening:*

YesNo
Fluoride Varnish:*

YesNo
Dental Sealants:*

YesNo
DENTAL INSURANCE INFORMATION – Required if you consent to sealants
Primary Insured Name:
Insurance Company:
Insurance ID Number:
Group Number:
Insurance phone:
Insurance holder's date of birth:

MonthDayYear
Date
State law requires a basic medical history for each child receiving service.
My child is taking (list medications):
My child is allergic to:
Any current medical/behavioral problems? (If yes, please describe)

AsthmaOther
If you said YES to screening and sealants, your signature below indicates:
As the legal parent/guardian, I hereby consent to the release and exchange of information, including any personal health information, between the dental
sealant staff, school staff, insurance carriers, the child’s dentist, applicable Coordinated Care Organization, and/or the Dental Care Organization of record.
I have received a copy of “Notice of Privacy Practices.”
Notice of Privacy Practices can be found here: https://roguecommunityhealth.org/wp-content/uploads/2024/07/RCH-Notice-of-Privacy-Practices.pdf
***********************************************************************************
IF YOUR CHILD HAS PERMISSION for the dental screening, and/or fluoride varnish applications and/or sealant application, please voluntarily fill
out the following information which assists us in obtaining grant funding to enable the continuation of the school-based dental health program. Your name
will not be used.
Migrant Worker:

YesNo
Seasonal Worker:

YesNo
Living Situation:

Own/RentLiving With OthersHotel/MotelCamping/Temporary Housing
Does your child have Dental Insurance:

YesNo
If yes to Dental Insurance, please check one:

Private InsuranceOHP
Demographics
Ethnic Group:

HispanicNon-Hispanic
Race:

Alaskan NativeAmerican IndianAsianBlackNative HawaiianPacific IslanderWhiteUnknownPatient Refused
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Rogue Community Health

2024-2025 School Year