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About
For Parents
For Schools & Facilities
Resources
FAQ
Contact

About
For Parents
For Schools & Facilities
Resources
FAQ
Contact

About
For Parents
For Schools & Facilities
Resources
FAQ
Contact

Consent Forms

CHILD FORM

ADULT FORM

CHILD FORM

If you are filling out the form for a child, please use the form below.

CHILD: Clean and Seal Dental Program Medical History Form

Child’s Name

Date of Birth

Gender

Male Female

School

Grade

Does your child have permission to participate?

Does your child have any allergies?

If yes, please select all that apply. You can choose multiple options by holding down ‘command’ key (on a Mac) or ‘ctrl’ key (on a PC).

Other?

What language does child speak best?

What language does parent speak at home?

What is your child’s race?

American Indian/Alaskan Native Asian Black/African American Hispanic/Latino White Other

Does your child see a doctor for regular checkups?

Yes No

Does your child see a dentist for regular checkups?

Yes No

If yes, name of the dentist:

Date of Last Dental Visit

Does your child get a cleaning every 6 months?

Yes No

Is your child taking any medication now?

Yes No

If yes, name of the medications:

Does your child need to take antibiotics (penicillin) before having dental treatment?

Yes No

Has your child EVER had an illness or condition?

Yes No

If yes, please check all that apply.

ADD/ADHD Diabetes Epilepsy/Seizure Asthma Heart Conditions/ Heart Murmur Other

Other?

If your child has MassHealth / Medical dental insurance, please complete below:

I understand that CLEAN AND SEAL DENTAL PROGRAM may use my child’s health information for treatment, payment and health care operations. A copy of the Notice of Privacy Practices will be given upon request. I have read and understand the dental program and services that may be provided to my child. I consent to have my child participate in the program. I authorize the dental program to provide a written summary of the examination-services to an official designated by my child’s school. I understand that these services do not substitute for an examination by a dentist and that my child should obtain an examination by a dentist within 90 days, if they have not had one. If needed, the dental program may share your child’s dental record with a dentist in the area. In addition, a list of dental offices will be given to your child as well. I understand that my child may continue to receive dental care from any other provider. If I have dental insurance, I acknowledge that this treatment may affect my future rights and insurance benefits, and I authorize my insurance carrier to be billed for any services provided.

Parent/Guardian Name

Today’s Date

Relationship to Child

Print Name

Phone Number

Email Address

I certify that the information provided is accurate and complete and that I have authority to sign this Agreement on behalf of Applicant.

ADULT FORM

If you are filling out the form for yourself or another adult, please use the form below.

ADULT: Clean and Seal Dental Program Medical History Form

Adult Name

Date of Birth

Age

Home Phone

Cell Phone

Email

Physician Name

Physician Phone

Health Insurance

Health Insurance #

Do you have any of the health issues listed below?

Yes No

If yes, please select all that apply. You can choose multiple options by holding down ‘command’ key (on a Mac) or ‘ctrl’ key (on a PC)

If answered ‘yes’ or ‘other’ to any of the above, please explain:

Does you need to take antibiotics (penicillin) before having dental treatment?

Yes No

If yes, why?

Do you take any medication now? Please list.

Yes No

Do you have any allergies? Please list.

Yes No

Have you been to a dentist in the past year?

Yes No

If yes, reason for visit?

Patient/Guardian Name

Today’s Date

Phone Number

Email Address

I certify that the information provided is accurate and complete and that I have authority to sign this Agreement on behalf of Applicant.

FORM DOWNLOADS

Child Consent Form:

Adult Consent Form »

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