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 Date of Birth: 


 YES, I give permission for my child to be examined and treated by a Big Sandy Health Care dentist, dental hygienist and staff at the school or on a Mobile Dental Unit located on school property.
  1.  I understand that my child’s teeth will be examined by a qualified Big Sandy Health Care dentist.
  2. I understand that the dental exam may include the use of digital dental x-ray equipment (digital x-rays generally result in less radiation exposure than traditional film).
  3. I understand that the preventive services, which may include cleaning and application of fluoride and sealants, may be provided by the dental hygienist without the presence of, but under general supervision of and according to a plan ordered by a dentist.
  4.  I understand the examination may determine that more treatment is needed beyond that which can be performed at the school or on the Mobile Dental Unit. I understand that, if indicated, Big Sandy Health Care will assist in referring my child to another dentist.
  5. While all the individual dental records are held by Big Sandy Health Care as confidential, I understand that a list of children who need follow-up dental treatment may be routinely provided to the school’s Family Resource Center.

CONSENT TO TREATMENT: I authorize the examination of my child by a Big Sandy Health Care dentist, including the performance of diagnostic digital x-ray. I authorize the provision of preventive care procedures by a Big Sandy Health Care dentist, dental hygienist and staff, as may be necessary or beneficial.  

RELEASE OF INFORMATION: I understand that the dental records and x-rays that are associated with my child’s evaluation and care are the property of Big Sandy Health Care. I authorize Big Sandy Health Care and its staff to release pertinent information from the patient’s record to any insurance company or agency which may be responsible for the fees for services rendered. In the event a Big Sandy Health Care dentist refers my child to another dentist, I authorize the release of my child’s dental records to that dentist (referral dentist). In addition, I authorize the referral dentist to release my child’s dental records to Big Sandy Health Care.

PAYMENT AUTHORIZATION: I hereby authorize insurance payment directly to Big Sandy Health Care of the benefits that might otherwise be payable to me. I understand that I will NOT be required to pay for services.

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