Questions? Call: 800.409.2563

Questions? Call: 800.409.2563

Student Permission Form

School: Columbia Middle - Tyrrell County Schools  Wrong School?

School Information

Taking care of your child’s teeth is important to keep them healthy. And, having your child seen by the in-school dentist is both easy & convenient for you.

A state licensed dentist will check your child's mouth & teeth, as well as provide a cleaning, x-rays as necessary, fluoride treatment and apply sealants, as needed. Additional care, such as fillings, may also be provided. A dental report card will be sent home with your child. By completing this form, your child will receive dental care at school about every 6 months.

Zip Code *
School*
If you don’t see your child’s school listed, please call one of our Care Coordinators at 800-409-2563.

Child Information

Thank you for choosing the in-school dentist to take care of your child’s teeth. Simply complete this easy step-by-step permission form.

By doing so, a state licensed dentist will regularly check your child's mouth & teeth, as well as provide a cleaning, x-rays as necessary, fluoride treatment and apply sealants, as needed. A dental report card will be sent home with your child. By completing this, the dentist will be able to see your child for their initial visit as well as all follow-up visits.

Child First Name *
Child Last Name*
Birth Date *
Gender *
Grade *
Teacher Name

Parent/Guardian Information

*
Your First Name*
Your Last Name *
Email Address *
Telephone *
Alternate Telephone
Address *
Apt
City *
State *
Zip Code *

Insurance Information

Insurance Type*

Medical History Information

DOES YOUR CHILD HAVE ANY PAST OR PRESENT MEDICAL CONDITIONS, DISABILITIES, BEHAVIOR OR OTHER PROBLEMS? PLEASE CHECK EACH CONDITION THAT APPLIES TO YOUR CHILD AND EXPLAIN IN THE SPACE PROVIDED. IF NO CONDITIONS APPLY, LEAVE BLANK.

Asthma

Allergies to foods

Behavior problems

Abnormal bleeding

Breathing Problems

Contagious diseases (including COVID-19)

Chicken Pox

Dental Problems

Diabetes

Hay Fever

Hearing Problems

Heart Condition

Heart Murmur

Convulsions

Hepatitis

Immune Disorders

Kidney disease

Latex Sensitivity

Liver disease

Measles

Mononucleosis

Mumps

Neurological Disorders

Psychiatric/Psychological

Stomach Problems

Seizures

Handicaps/disabilities

My child has allergic (or adverse) reactions to medications or other substances.

My child’s immunizations are NOT current.

My child is under the care of a physician.

I have been told previously my child needs antibiotics or premeds before treatment.

My child has been hospitalized, had surgeries or has/had a serious illness (including COVID-19).

Other

PLEASE DESCRIBE CHECKED BOXES ABOVE. List Current Medications

List Current Dental Concerns
Important Notice & Consent
I understand and authorize Theodore F. Mayer, DDS P.A. (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 or to place a crown over the tooth, 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. If you are insured with Medicaid or NC Health Choice for Children, we are required to send your clinical data to NC HealthConnex. If you would like to opt-out of your information being shared by HealthConnex, please visit https://hiea.nc.gov/patients/your-choices. This signed consent authorizes my child’s initial and future dental visits. I may withdraw this consent at any time in writing.
I've read the statement and I agree.




For more information, please visit MobileDentists.com.