By signing below I am consenting to routine dental cleanings as well as any necessary dental treatment for one school year:

I the Parent/Guardian understand and give permission for School Smiles dentists to provide the following services on my child at school which includes: exam, x-rays, cleaning, fluoride, silver diamine fluoride, and sealants as needed for 6 month check-ups. I also give permission for my child to receive dental treatment as needed in the form of restorative fillings and local anesthetic to numb the area and any changes. I understand that during treatment it may be necessary to change or add procedures because of conditions found that were not discovered during the initial exam. For example: larger fillings, stainless steel crowns, pulpotomy (root canal on baby tooth) and extractions (pulling the tooth).

FINANCIAL STATEMENT: Please be aware that any treatment that is rendered may affect future benefits that your child will receive under private insurance, health insurance program, Medicaid, and Hoosier Healthwise.

* Please note: If your child needs treatment beyond fillings, such as stainless steel crowns, pulpotomies or extractions, additional consent WILL be obtained. If your child requires treatment outside of what can be provided by School Smiles, a referral will be provided to you.

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