Mobile Dental Clinic Forms

Mobile Dental Clinic forms are available here! Please print and send in with your child or email to ebonham@bakersfield.k12.mo.us

SCHOOL BASED DENTAL CARE

Dear Parent/Guardian:

Missouri Ozarks Community Health will be visiting your school to provide onsite dental services through our mobile dental clinic. We will be visiting Bakersfield School November 17-20, 2020.

The initial visit will consist of diagnostic and preventive services. These dental services include but are not limited to screenings, exam, x-rays, cleaning, fluoride and sealants. If treatment beyond preventive services is recommended, a separate consent form will be sent home to review prior to any further treatment. This can include but is not limited to fillings, crowns, extractions, and space maintainers. A referral to one of our main clinic sites or for specialty care may be required.

If you currently do not have a dentist or are looking for a dental home for your child, we encourage you to sign up. We accept Medicaid/MOHealthnet and private dental insurance. We also offer a sliding fee program for children without insurance, with services provided for all children regardless of the ability to pay. If you would like your child to receive dental services, please fill out the attached patient information form and return it to school as soon as possible. Please make sure you complete all information, front and back, which includes a consent and agreement statement that must be filled out and signed by the parent/ guardian.

Sincerely,

Sybil A. Fortner, D.D.S

Dental Director

Ava (417)683-5739 504 W Broadway , Ava MO

Mansfield (417)924-8809 804 N Highway 5, Mansfield MO

Gainesville (417)679-2775 201 S Elm, Gainesville MO

Cabool (417)962-5422 904 Zimmerman, Cabool MO

Mt. Grove (417)926-1713 1604 C N Main, Mt. Grove MO

Houston (417)967-0772 1340 Sam Houston Blvd., Houston MO

SCHOOL BASED DENTAL CARE

PATIENT INFORMATION and CONSENT FORM -- Click below for the form or fill out the information below and print

https://5il.co/mymn

Missouri Ozarks Community Health will provide dental services at your child’s school during school hours. Your child’s participation is voluntary. In order for your child to receive dental services you will need to complete this form and return it to the school. Please contact your school nurse or Missouri Ozarks Community Health if you have any questions.

PATIENT INFORMATION:

Patient’s Name:_________________________________________________________________________

Name patient wishes to be called:__________________________________________________________

Date of Birth:_______/______/__________ Patient’s age: ________________ Sex: M / F

Grade:_________ School patient

attends:___________________________________________________

Parent/Legal Guardian Name:______________________________________________________________

Home address (mailing):___________________________________________________________________

City:_______________________________________ State: ________________ Zip: _________________

Telephone numbers: Home:________________________ Cell:_________________________________

Work:___________________________________ (Please circle best # to call during school hours)

Preferred Pharmacy:______________________________________________________________________

Medicaid/ MOHealthNet: YES ________ NO __________

ID Number: ____________________________

Private dental insurance: YES ________ NO __________

Insurance Company name:______________________________ Ins. Phone:_____________________

Name of Insured Adult:_________________________________ DOB of Insured:__________________

Member/Policy #:________________________________ Group #:______________________________

No Insurance Coverage: _________

Is your child eligible for free/reduced school lunches? YES ________ NO __________

Has your child seen a dentist before? YES____ NO_____

Date of last dental visit:____________________

If yes, treatment received: _____________________________________________________________

Please check the reason(s) for seeking dental care for you child:

Routine checkup _____ Appearance of teeth ____ First visit _____

Swelling of face _____ Toothache _____ Crowding of teeth _____

Accident to the teeth ____ Bleeding around the teeth____ Other (specify) ___________________

DENTAL AND MEDICAL HISTORY OF YOUR CHILD: (Please circle YES or NO where indicated)

Has the child had any unusual or unpleasant experiences in a dental

or medical office?…………………………………………………………………………….. YES NO

Has the child ever had any injuries to the face, mouth or teeth?.............................................. YES NO

Has the child ever had a toothache? ………………………………………………………………... YES NO

Does the child have any oral habits such as thumb sucking?................................................... YES NO

Is the child presently in good health?........................................................................................ YES NO

Is the child presently under the care of a physician?................................................................. YES NO

Has the child been in a hospital or had surgery?....................................................................... YES NO

Is the child’s immunization record up to date?........................................................................... YES NO

OVER, PLEASE »

Does your child take any fluoride supplements?......................................................................... YES NO

Is the child taking any medications at this time?................................................................... …… YES NO

If yes, please list:______________________________________________________________

Has the child had any unusual reaction or allergy to medication like

Penicillin, aspirin, or local anesthetics?.............................................................. YES NO

If yes, please explain: _____________________________________________

Does your child have a history of seasonal allergies?.................................................................. YES NO

Does your child have a latex allergy?........................................................................................... YES NO

Does your child have any allergies not listed above? ____________________________ YES NO

Does the patient have a history of:

Abnormal bleeding………… YES NO Cerebral Palsy…………………. YES NO

ADD/ADHD…………………… YES NO High blood pressure…………… YES NO

AIDS or HIV…………………… YES NO Kidney problems.……….…… YES NO

Liver disease………………… YES NO Convulsions (seizures)/Epilepsy YES NO

Rheumatic fever……………… YES NO Autism ………………… YES NO

Fainting/Dizziness………………. YES NO High fevers…………………… YES NO

Diabetes……………………… YES NO Tonsillitis………………………. YES NO

Tuberculosis (TB)……………… YES NO Behavioral problems………… YES NO Anemia………………………….. YES NO Hepatitis…………………………. YES NO

Nutritional problem……………… YES NO Vision problems…………………. YES NO

Speech problems……………… YES NO

Hearing problems…………… YES NO

Birth defects…………………… YES NO

Cancer or tumors……………………..YES NO -----à If yes, please explain __________________________

Congenital Heart Defect .…………...YES NO ------àIf yes, does child require premedication?YES NO

Asthma…………………………………YES NO ------àIf yes, when was last asthma attack?_______________

Do they require an inhaler? YES NO

Any special problems not listed above? __________________________________________________________________

CONSENT FOR DIAGNOSTIC AND PREVENTIVE TREATMENT AND ASSIGNMENT OF BENEFITS:

I consent for my child to receive preventive dental services in Missouri Ozark Community Health’s mobile clinic.

Dental preventive services include but are not limited to screenings, exam, x-rays, cleaning, fluoride and sealants. If treatment beyond preventive services is recommended, a separate consent form will be sent home to review prior to any further treatment.

I hereby give consent to the Missouri Ozarks Community Health staff to perform those procedures and treatments, which are deemed necessary with the exception of :

Assignment of benefits: I understand that eligible services may be billed to Medicaid and/or private insurance. I hereby instruct and direct all proceeds of insurance to be paid to Missouri Ozarks Community Health to be paid by check for the dental benefits allowable, and otherwise payable to me, under my current insurance policy as payment toward the total charges for the professional service rendered. I authorize MOCH to release or receive information on eligibility and/or benefit information for the purpose of filing insurance claims. I also understand that additional information may be needed from my file to achieve maximum benefits. I acknowledge receipt of the HIPAA Notice of Privacy Practice attached to this consent form. I understand that this consent may be revoked at any time upon my request.

This treatment consent will be in effect for the year August 1, 2020 through July 31, 2021.

Patient Name:__________________________________

Parent/Legal Guardian Signature:__________________________________________ Date________________________