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 Insurance Information
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Community Care Worker Contact Information
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Dental Services
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Medical Information
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Dental History

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General Information

Please have your insurance card available as it is needed to complete this form.

*Patient’s Full Legal Name

*Gender as marked on insurance

Female

Male

* Date of Birth:

*Mailing Address

*Town

*Zip Code

*Best Contact Number

*Does the phone take texts?

Yes

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

Dental Insurance Information

*Please Select:

MaineCare

Other Insurance

*MAINECARE INSURANCE- ID #

*INSURANCE- ID #

Please SEND A COPY OF YOUR INSURANCE CARD front & back to: FAX: (207) 513-1197, EMAIL: Info@ToothProtectors.org, TEXT: (207) 402-8038

Or Upload Here

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Community Care Worker Contact Information

*Name

*Contact Number

*Are you responsible for changes to appointments and other concerns that we may need to speak with the patient about?

Yes

*Do we contact the patient directly for questions?

Yes

*Does this patient require interpreter services?

Yes

Language Spoken

Dental Services

Services covered by insurance will be completed.

Any non-covered services charges will be discussed before performing services

*Must choose 1 service below

Full dental cleaning

Fluoride treatment

Preventative Tooth Sealants

Education & Screening Only

SDF (Cavity Medication-contains fluoride)

Temporary Fillings (contains fluoride)

Referral for Treatment

Medical Information

*Does this patient require a pre-med prior to service? (Heart conditions, Joint Replacements)

Yes

If yes, what is the condition or when was the replacement done?

*Has this patient had a stroke within the last year?

Yes

If yes, when?

Please list any allergies

Please list any medications

Please list any other medical conditions

Dental History

*Last Dental Visit

6 Months

1 Year

3 Years

5 Years or More

Never

What was the visit for?

*How often do you brush?

Once a day

Twice a day

None

*Do you floss?

Yes

*Mouth rinse?

Yes

*Do you have any pain?

Yes

If yes, please describe

I give permission for myself or my child to receive dental services provided by licensed registered dental hygienist with Public Health Status (PHS) or IPDH. Tooth Protectors Inc. (TPI) may release basic information confirming myself or my child’s services, for school screenings, dental offices, and others for the benefit of myself or child. I understand that the services provided do not take the place of an exam by a dentist. I understand that TPI is HIPAA compliant and all records are kept confidential an I understand that if I have listed insurance information for the patient & 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

*Parent/Guardian Signature

*Parent/Guardian PRINTED NAME

*Date