Thank You!

Thank you for filling out our School Dental Hygiene Program Permission Form. We will add your child to the list to be seen for dental services.

Please complete this form for each child you wish to be seen!

Pay Your Bill Online…

If you’re using self pay, pay now using the link below or visit the website toothprotectors.org/pay to pay your bill anytime!

PAY NOW

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General Information
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Dental Services
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Insurance Coverage
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Medical / Dental History

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General Information

Please have your insurance or credit/debit card available as it is needed to complete this form.

THIS FORM PROVIDES PERMISSION FOR YOUR CHILD TO BE SEEN TWO TIMES DURING THIS
SCHOOL YEAR FOR DENTAL CARE

PLEASE FILL OUT ONE FORM PER CHILD TO BE SEEN

*School’s Full Name

*Grade

Teacher

*Child’s Full Legal Name

*Gender as marked on insurance

Female

Male

* Date of Birth:

Age

Mailing Address

Town

Zip Code

*Home Phone

*Cell Phone

Does the phone take texts?

Yes

*Email (must have to contact you & future communications)

Dental Services

*Please check ALL services you would like your child to receive – fees are for non-insured patients only

I want Screening and Fluoride provided by the State Oral Health Program (SOHP)

I want ALL services my child needs that are covered by my insurance plan and services provided by the State Oral Health Program (SOHP). This includes Screening, Assessment, Oral Health Education, Full Cleaning, Fluoride and if needed Sealants, Temp Fillings, SDF, Referrals for restorative care, braces, extractions.

I want ONLY the services marked BELOW (check all services that you want your child to receive)

I DO NOT WANT any dental services. My child already receives regular dental cleanings 2 times a year.

Warning: You do not need to fill out this form. Only fill out if you WANT your child seen!

*Please Select

Dental Cleaning (AGE 1-12= $75, AGE 13 and over $85)

Oral Hygiene Instruction ($30)

Nutritional Counseling ($30)

Fluoride ($35)

Preventative Tooth Sealants ($40 PER TOOTH)

Temporary Filling ($70)

SDF ($20)

Insurance Coverage

We currently DO NOT accept: Humana, Harvard Pilgrim, BCBS Federal – Accepted insurance is subject to change without notice

*Please Select:

MaineCare Insurance

NO Dental Insurance- All services paid for by the State Oral Health Program (SOHP)

Other Dental Insurance – Delta, Cigna, United, Aetna, etc.

Self Pay out of Pocket

*Services covered by SOHP at no charge for Uninsured/Under Insured

Screening and Fluoride

Screening Only (no fluoride)

*Would you like to pay for services NOT covered by the Maine State SOHP if your child should need them?

Yes

*MAINECARE INSURANCE- ID # for Child:

*Insurance Company Name:

*Policy Holders Full Name:

*Date of Birth

*Group #

*Policy/Subscriber ID or Social Security #

*Payer ID

*Provider Phone # (located on the back of insurance card)

*How is patient related to Policy Holder?

Child (18 & under)

Dependent (19 & over)

Self

Spouse

Significant Other

Life Partner

Other

If Other, please enter

Please SEND A COPY OF YOUR INSURANCE CARD front & back to
TEXT: (207) 588-1798

Or Upload Here

mpg mpeg pdf jpg jpeg png psd tif tiff

There will be a $25.00 fee for INSUFFICIENT FUNDS

*Self Pay Methods

Attach to this COMPLETED permission form and return form & payment to your child’s School.

Check needs to be sent to the school / nurse Prior to the dental clinic date.

Attach to this COMPLETED permission form and return form & payment to your child’s School.

Money Order needs to be sent to the school / nurse Prior to the dental clinic date.

*Check Number

*Please total services requested

Former or No Dental MaineCare insured patients please read fully: “I understand, that my child no longer has active MaineCare coverage. I understand that I will be paying out of pocket and by signing this permission form, I understand that I am responsible for payment of services rendered”

Medical / Dental History

*Has your child ever needed Antibiotics for dental treatment? If yes, please take the same precautions prior to treatment

Yes

Please list dental concerns you may have

List any Allergies your child has

Does your child have any of the following (select all that apply):

Special Need

Hemophilia

Asthma

ADHD

Autism

Cancer

Anxiety

Other

List ALL Medications

Does your child receive regular dental cleanings twice per year?

Yes

Had a cleaning in the past 6 months?

Yes

Patient was last seen (month & year):

Patient last seen by:

Services received during Last Visit (Extractions & a cleaning are never done at the same appointment)

Cleaning

Fluoride

Sealant (protective coating on the biting surface of the tooth to prevent cavities)

Fillings

Exam

X-Ray

Extraction (tooth pulled)

Braces (orthodontic appointment where braces are installed, removed, or adjusted)

Space Maintainer

Does your child have a history of cavities?

Yes

Does your child Brush/floss at least 2 times Daily?

Yes

Does your child consume sugary products regularly?

Yes

Does your child use a fluoride Rinse?

Yes

I give permission for my child to receive dental hygiene services TWO (2) TIMES DURING THIS SCHOOL YEAR. (if my child’s school can offer it two times this school year.) I understand that I will receive a reminder of the 2nd dental clinic date from the school and/or TPI and that my child will be automatically added to the dental clinic list to be seen. It is my responsibility to notify either TPI (207) 513-1111 or my child’s school prior to the 2nd dental clinic spring date to make any changes regarding my child’s medical/dental history or removing them from the spring dental clinic list. I understand that the services provided today do not take the place of a complete dental exam by a dentist. However, dental services are being provided by a registered, licensed dental hygienist with Public Health Status (PHS) associated with Tooth Protectors Inc. (TPI), at school, during school hours. I have entered my child’s information on this permission/consent form accurately and truthfully and understand that it is my responsibility to report/remember my child’s date of dental service. I am also responsible to report this date when needed for current/future dental treatment and cannot hold TPI responsible if the information is not accurate/truthful on this form regarding current and/or previous treatment/appointments with other dental office locations. I agree to notify my child’s school and/or TPI at (207) 513-1111 of ANY changes to my child’s medical/dental history or of a dental home. I give permission for TPI to release patient and dental service information to benefit my child. I understand that services provided do not take the place of a complete exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential and that claims to insurance (if applies to your child) will go through TPI per electronic transfer or mail. Services not paid for by my insurance are my responsibility. I understand that if I have listed insurance information for my child & he/she does NOT have dental coverage at the time services are provided, and/or received the same services by another dental provider within 6 months and I did not divulged this above, than I assume all responsibility for payment of services received and understand that I will receive a bill from Tooth Protectors Inc. I understand that the coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I understand that COVID-19 is extremely contagious and is believed to spread by person -to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Tooth Protectors Inc & all staff are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of Covid-19 However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with receiving dental treatment. I hereby acknowledge and assume the risk of myself /child becoming infected with COVID-19 through this elective dental care. I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with dental care for myself/child.

*Signature

*Parent/Guardian PRINTED NAME

*Relationship to child/patient

*Date