Important Notice & Consent
I understand and authorize Big Smiles Utah, P.C. (Provider) and its affiliated dentists or dental hygienists to provide the following services to the named child for whom I am the custodial parent or
legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants, as well as the application of Silver Diamine Fluoride to treat the progression of
tooth decay. I also authorize the dentist to fill any cavities with composite (white) instead of amalgam (silver) fillings and to place a crown over the tooth, if needed. I understand that Medicaid does
not pay for composite fillings as an upgraded service, but I will not incur an additional charge for this service given the practice’s fee structure. I authorize Provider to extract any problem baby teeth,
perform a pulpotomy (baby tooth nerve treatment), place space maintainers or perform other dental treatments as needed. I understand that there are risks to dental treatment including swelling
or pain that may occur from the treatment or injection of a local anesthetic, or allergic reaction. (For additional information regarding the risks of treatment and treatment alternatives, please call
the number provided.) I understand that a portion of my child’s dental examination may be performed remotely and that clinical information (such as x-rays) may be collected and sent electronically
to another site for the dentist’s evaluation. I consent to these teledentistry services and understand that while confidentiality protections apply, the use of third party electronic transmissions may
present additional privacy risks. I understand that I have the right to access medical information related to teledentistry services. I authorize & direct Provider to bill & collect payment from any
Medicaid, insurance, or other payer. I authorize my child’s school to make available to Provider and its billing agent my child’s insurance information in order to bill payer for services. If I have
private dental insurance, I will be billed for & agree to pay any deductibles and/or co pays. Treatment by the in-school dentist may affect future benefits that your child may receive under private
insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at the time of service, services will be provided without my presence. I consent to the Provider sending
text messages about the school dental program. I acknowledge that text messaging is not a secure form of communication and presents additional privacy risks. (Message and/or data fees may
be charged by your wireless service provider; to discontinue, reply “STOP” to any message received from us. You also agree to receive pre-recorded and/or auto-dialed telephone calls relating
to the school dental program at the land-line and/or mobile telephone numbers provided on this consent form.) I have received the Notice of Privacy Practices (NPP) attached to this form and
consent to the release of my child’s medical record information, including records obtained from other providers, and any HIV/AIDS, communicable disease, sexually transmitted disease, drug and
alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor and/or administrative service provider and their subcontractors for use and disclosure
relating to my child’s treatment, payment for services and health care operation purposes. I authorize the release of examination, treatment, and demographic data to Utah’s state and local health
departments to assist them collecting data on the dental needs of those in Utah. This signed consent authorizes my child’s initial and future dental visits. I may withdraw this consent at any time
in writing.
You Must Read and Agree to the Important Notice & Consent Statement Prior to Submitting
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