Dental Consent Form

School Name*
Student Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Grade*
Gender*
Race*
Ethnicity*
Does the child have dental insurance?*
- Yes
- No
Hidden
KanCare / Medicaid:
KanCare / Medicaid Dental Insurance
If you do have Dental Insurance please complete the section below. We will bill your insurance for services provided.
KanCare #
Title Number

Commercial / Private Insurance:
Subscriber Name
First Last
Subscriber Date of Birth
MM slash DD slash YYYY
Subscriber SSN
Policy #
Group #

Parent / Guardian
Guardian Name*
First Last
Daytime Phone #*
Mobile Phone #
Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Guardian Email Address*
Guardian Date of Birth*
MM slash DD slash YYYY
Information
- YES, I’d like more information about Heartland programs, services and special events.
Heartland offers medical, behavioral health, psychiatric, dental and physical therapy services to all, regardless of income of insurance status. Please check the box to receive more information, updates and reminders about Heartland programs, services and special events. We will not share your information with anyone.
Parent / Guardian Digital Signature*
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.
Date of Parent / Guardian Signature*
MM slash DD slash YYYY
Date of Provider Signature

Dental Consent Form

Step 1 of 4

KanCare / Medicaid:

Commercial / Private Insurance:

Parent / Guardian

Medical History Form