As parent or legal guardian of the patient named above, I give Heartland Community Health Center permission to provide my child with dental sealants, fluoride treatment, sliver diamine fluoride treatment, x-rays, and dental cleanings. I also acknowledge that the Privacy Practices were and are available for my review. This consent is valid for one year from the Parent/Guardian Signature date below.
I understand that all patient information is protected and will only be exchanged with staff employed/contracted by Heartland Community Health Center and, in certain circumstances, with the school (applicable only if your child’s treatment occurs as part of a school-based program).
I authorize Heartland to release the information necessary to process insurance claims and authorizepayment directly to Heartland.