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.