Cavity Prevention Clinic Permission - Central District Health

Cavity Prevention Clinic Permission Form

CDH provides WIC services to those who qualify.
Please scan the QR code for more information and to apply.
https://signupwic.com/

Parent or Guardian's Details

Same as Insured

Parent/Guardian Name

Home Address

City

State

Zip

Phone

Permission

I give permission for my child to participate in the Sealant Clinic and receive preventive dental services that may include visual dental screening/assessment, sealants, fluoride and re-evaluation and repair (if necessary) of sealants at a later date. I also acknowledge that I have had the opportunity to review Central District Health’s (CDH) Notice of Privacy Practices located at: https://cdhbackupstg.wpenginepowered.com/health/clinics/#hipaa I authorize the release of information on my child’s dental visit to CDH, my child’s elementary school, Medicaid (Idaho Smiles) or other insurance companies as applicable. I authorize and direct payment of the dental benefits otherwise payable to me, directly to CDH. I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving the dental treatment described above.

I decline participation in the Sealant Clinic

Parent or Guardian’s Signature

Clear

If you are human, leave this field blank.

The programs impacted by this change are:

Cavity Prevention Clinic Permission Form

Cavity Prevention Clinic Permission Form

Student Demographics

Services

Insurance(Must be Complete to Receive Services)

Parent or Guardian's Details

Permission