Important Notice & Consent
I understand and authorize Elliot Paul Schlang, DDS, Professional Corporation (Provider), its affiliated dentists and dental hygienists, and externs from UCLA and UCSF Schools of
Dentistry under dentist supervision, 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, digital x-rays (patient will be exposed to a minimal dose of radiation), dental sealants (a thin layer of resin bonded to the enamel grooves of molars to protect
them from tooth decay), Preventive Resin Restoration (PRR - removal of minor decay in the enamel grooves and the placement of a composite sealant), as well as the application of Silver
Diamine Fluoride to treat the progression of tooth decay. I authorize the dentist, or UCLA/UCSF School of Dentistry Externs under supervision, 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 Denti-Cal number in order to bill payer for services. Further, I authorize the release of my child’s Denti-Cal number by Provider or its billing agent to Denti-Cal.
If I have private dental insurance, I will be billed for & agree to pay any deductibles and/or co-pays. 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, simply 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. 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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