Vineyard Smiles 2017-2018 Registration Form
The dental program is available to all students. You do not need to have insurance to participate.

We treat patients without a dentist or dental home.

We treat children who have Masshealth without a dentist.

We treat kids who have Private insurance without a dentist.

We treat children who have no insurance without a dentist.

Services are provided at your child’s school by Massachusetts licensed dentists, licensed hygienists and dental assistants. In some cases, dental students may accompany the dental professionals to provide educational and preventive services.

All students will receive an oral health screening, a fluoride treatment, and oral hygiene instruction by the dental provider.

Most Students will receive an exam, treatment plan, dental cleaning, dental sealants, fillings, and x-rays as needed.

Some students may need to be scheduled for further dental treatment or specialty services and will be referred to a dental provider in your community.

Referrals are dependent upon the extent of the Dental Cavities / Gum Disease as well as the behavior of the patient.

Informed consent indicates your awareness of sufficient information to allow you to make an informed personal choice concerning the patient’s dental treatment. Most patients do not encounter any difficulties with their treatment. In rare instances, a patient may experience some discomfort or pain. If the patient indicates any resistance to the dental procedure, we will discontinue the treatment.

The Tell-Show-Do technique is often used to gain the cooperation and confidence of the dental patient. The dental provider explains what they are going to do then shows what they are going to do with instruments on a model. The provider makes every effort to be a partner in care with the patient and family making the dental visit pleasant and informative.

You do not need to have insurance to participate.

If you have insurance, please send a copy of your insurance card, it will be billed directly upon verification.

Your child may continue to receive services from your own dentist. However, services provided by CMOHS, LLC may affect insurance coverage for other dental visits.

    Please be sure to complete all sections.
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    Please fill out all sections to the best of your ability.
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    You do not need to have insurance to participate. If you are uninsured, leave this section blank
  • Please enter your 12 digit Masshealth
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  • By filling out the following you are consenting for your child to participate.

    YES, I give permission for my child to participate in the CMOHS, LLC Dental Program
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