Dental Clinic by Prevention Partners
April 11, 2008

Dear Parent or Guardian:

Your child may be eligible to participate in a Dental Hygiene Program April 11, 2008. If your child is not currently established with a dentist and has not be treated by a dental hygienist or dentist in the last 6 months and 1 day, they may be seen by a Registered Maine Dental Hygienist. This program is held during school hours. A new form needs to be submitted each time your child participates.

We do Oral assessment/inspections, oral hygiene instructions, cleanings, sealants of molars and premolars, temporary fillings and preventive care. Referrals to dentists for urgent care, when possible. This Confidential program is provided at no cost only to children who have MaineCare/Medicaid. Others may self-pay, the day of treatment. All records are kept confidential.

Students in the program will be excused from class for about 20 minutes, one to two times a year to receive this care. Only students with a completed and signed permission slip will be seen.
If you would like your child to participate in this program, please send back the completed form at the bottom of the page as soon as possible to your school’s nurse. Please call Linda at Prevention Partners(207-633-9716) if you do not have MaineCare and would like to be a self-pay patient. ____________________________________________________________________________
School Name ______________________________________________ Grade___________
Child’s Name_________________________________________________________________

MaineCare/Medcaid#____________________________________Date of Birth ___-___- ___
(no other insurance accepted)
Address______________________________________________________________________
Phone Number____________________________Place of Birth_________________________
Current Medication or Medical treatments___________________________________________
_____________________________________________________________________________
Allergies_____________________________________________________________________
Heart Condition _______Heart murmurs_____ Mitral valve prolapse_____________________
Physician’s Name: _____________________________________________________________
Has he/she seen a dentist? _(Y) (N) Date of last visit__----__Location of last vist____________
Services received at last visit (circle) cleaning, fluoride, sealants, temporary filling, other: ____
Do you have any dental or medical concerns?________________________________________
Does your child receive daily fluoride? YES, NO Does your child eat Breakfast? _______
Yes, I give permission for Prevention Partners to provide preventive services to my child.

______________________________________ ____________________________________
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