Children’s Dental
Foundation
The Children’s Dental
Foundation can help and will be at your school starting
Thursday, September 29, 2016
· We provide dental cleanings to school-aged children on BadgerCare (Forward Card).
· If further care is needed, we can get you where you need to go!
The Children’s Dental Foundation is a Marquette County based non-profit that partners with the County Health Department and a local dental hygienist to provide dental cleanings to school-aged children on BadgerCare.
Dental cleanings are provided at school in a discrete manner, during school hours using mobile equipment which meets the same standard as a dentist’s office.
The dental hygienist will note any clear concerns during the appointment and refer children for a full dental exam. We can assist you in locating a
local provider to help with any further care.
Please complete and sign the bottom portion and medical history on back and return to school or call
the Marquette County Health Department at (608) 297‐3135 by September 21st.
Yes, I am interested in my child receiving a dental cleaning at his/her school provided by the Children’s Dental Foundation. I
understand that any medical records generated as a result will remain confidential, and authorize the release of information
for
child’s name
to partnering dental providers, the dental hygienist, and the Marquette County
Health Department. PLEASE COMPLETE & SIGN FRONT AND BACK OF THE FORM. Thank you.
Parent/Legal Guardian
Signature Date
Children’s Dental Foundation Medical History and Parental Consent
Please answer the medical history questions below and certify they are accurate with your signature.
Child’s Last Name: / Child’s First Name: ______Date of Birth: / BadgerCare (Forward Card) Number
Phone Number: / Grade______
Is your child generally in good health?
Does your child have any allergies? (evergreen, tree sap, spices such as nutmeg, paprika, mace, cloves, or chrysanthemums?
Other
Does your child have any special health care needs?
Does your child have any history of infective endocarditis
(heart infection)?
Has your child ever had artificial heart valves, patches, shunts, or conduits placed in his/her heart?
Has your child ever had a heart transplant and developed cardiac valvuopathy (problem in a heart valve)?
Does your child have a congenital heart condition?
Has your child ever had a synthetic replacement or transplants
(hip, knee, etc.)?
Yes ¨ No ¨
Yes ¨ No ¨
Yes ¨ No ¨
Yes ¨ No ¨ Yes ¨ No ¨ Yes ¨ No ¨
Yes ¨ No ¨
Yes ¨ No ¨
This signature certifies that the medical history provided is accurate and provides consent to the Children’s Dental Foundation and Marquette County Health Department to conduct a dental cleaning, pre-exam and fluoride varnish, and seek reimbursement through Medical Assistance when applicable for these services.
Parent/Legal Guardian
Signature
Date