NKY Healthy Smiles Program

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* 1. Student Registration

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* 2. Birthdate

Birthdate

Date

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* 3. Social Security Number

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* 4. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number

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* 5. School Information

School

Grade

Teacher

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* 6. Parent/ Guardian Information

Name

Relationship to Child

Parent/ Guardian Birthdate

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* 7. CONSENT FOR DENTAL SERVICES- You must sign for your child to be seen. Of my own free will I consent to dental care which may include dental screening, fluoride, cleaning and sealants given to my child by NKY Health dental hygienists or agents of this health department. NKY Health registered nurses may provide dental screening and fluoride only. I understand that no guarantees are being made as to the effect of any exam or treatment on my child. I also understand my child may be tested for HIV infection, hepatitis B, or any other disease carried by blood or body fluids if a health care worker is exposed to my child’s blood, body fluids or tissue. This form, when signed and filled in, contains protected health information and the information is to be protected according to the Health Insurance Portability and Accountability Act (HIPAA). My signature below acknowledges my receipt of Northern Kentucky Health Department’s “NOTICE OF PRIVACY PRACTICES” which is available on https://nkyhealth.org/oralhealth or at the school’s office. I understand that no dentist is present for the dental procedures, and the public health dental hygienists are working under the supervision of Jonathan Rich, DMD. These services do not take the place of regular dentist visits, and all children will be referred to their own dentist for a full exam. I also understand that my child might receive fluoride 2 times during the school year and may be checked for the retention of any sealants placed during the following school year.

Parent/Guardian signature

Date

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* 8. Is your child currently covered by Medicaid?

Yes

No