Mobile Dental Consent Form / Formulario De Consentimiento Para Exámen Dental Servicios Móviles

The General Dentistry 4 Kids Mobile Dental Unit will be serving your child’s school. Our mobile dental services now give your child the opportunity to receive a comprehensive dental exam, including x-rays, dental cleaning, fluoride, and sealant application by one of our licensed dental providers without missing school. After your child’s visit, we will provide a dental report card that lists what services were provided that day and any additional information. If your child is in need of treatment, a member of our team will contact you to schedule an appointment. 

La Unidad Dental Móvil General Dentistry 4 Kids estará al servicio de la escuela de su hijo/a. Nuestros servicios dentales móviles ahora le brindan a su hijo la oportunidad de recibir un examen dental completo, que incluye radiografías, limpieza dental, fluoruro y aplicación de sellador por parte de uno de nuestros proveedores dentales con licencia sin faltar a la escuela. Después de la visita de su hijo, le proporcionaremos una boleta de calificaciones dentales que enumera los servicios que se brindaron ese día y cualquier información adicional. Si su hijo/a necesita tratamiento, un miembro de nuestro equipo se comunicará con usted para programar una cita.

 

Patient Information

Sex

Responsible Party Information

Questionnaire

Parents/Guardians: Please note the following questions pertain to the patient being seen by our mobile unit. Please answer all questions for your child.
Are you under a physician's care?
Are you taking any medications or substances?

Are you taking a blood thinner?
Do you have any problems with penicillin, antibiotics, local anesthetics (Novocaine) or other allergies?
Are you pregnant or suspect you are?
Have you ever been treated for heart disease?
Have you ever had rheumatic fever?
Do you have high blood pressure?
Have you ever had radiation treatment, chemotherapy, or any other?
Do you have any blood disorders such as anemia, leukemia, hemophilia, etc?
Have you ever bled excessively after being cut or injured?
Do you have any kidney or liver problems?
Do you have a history of seizures or epilepsy?
Do you have asthma?
Are you HIV positive?
Have you had or do you test positive for hepatitis?
Do you smoke, chew, use snuff or any other forms of tobacco?
Do you habitually use controlled substances?
Are you allergic to any medication or substances?
Are you sensitive to any metals or latex?
Do you take birth control medications?
Do you have a pacemaker or an artificial heart valve implant?
Are you aware of having a heart murmur?
Have you ever had a serious illness, major surgery, or cancer?
Do you have any soreness, clicking, or popping in your jaw joint?
Do you have any artificial joints / prosthesis?
Have you ever received a blood transfusion?
Do you have any stomach problems?
Are you a diabetic?
Do you have any of the following: ADD, ADHD, or Autism Spectrum Disorder?
Do you have AIDS?
Do you or have you had tuberculosis?
Do you consume alcoholic beverages?

I consent that my child will receive a comprehensive dental exam, including x-rays, dental cleaning, fluoride, and sealant application by one of our licensed dental providers.