EmailMe Form - ARCHIVEVineyard Smiles 2014-2015 Registration Form

ARCHIVEVineyard Smiles 2014-2015 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.

PATIENT INFORMATION
Please be sure to complete all sections.
Child's Name *
First Last
Date of Birth *
MM / DD / YYYY
Gender *
Male
Female
School Name *
Grade *
Homeroom Teacher / Room Number *
Parent / Guardian Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Best Phone to Reach you during School Hours *
### - ### - ####
Home Phone
### - ### - ####
Parent Email *
What language does parent speak? *
Has your child been to the dentist in the past year? *
Yes
No
If yes, please write date and reason for visit:
What is your child's race?
Asian
American Indian / Alaskan Native
Black / African American
Hispanic
Native Hawaiian / Pacific Islander
Biracial / Multiethnic
Caucasian
Other
Unreported / Not specified
MEDICAL INFORMATION
Please fill out all sections to the best of your ability.
Does your child see a doctor for regular check-ups? *
Yes
No
Physician's Name
First Last
Physician's Address

Street Address City State / Province / Region Postal / Zip Code Country / Region
Physician's Phone
### - ### - ####
Is your child allergic to any medicines, latex or filling materials? *
Yes
No
If YES, please explain:
Does your child need antibiotics before dental treatment? *
Yes
No
If YES, please explain:
Does your child take medications on a routine basis? *
Yes
No
If YES, please explain:
Does your child have a developmental disability? *
Yes
No
If YES, please explain:
Has your child ever had any of the following? *
AIDS/ARC/HIV
Asthma
Birth Defects
Blood Disorders
Cytomegalovirus
Congenital Heart Disease/Defects
Diabetes
Epilepsy/Seizures
Fainting Spells
Heart Disease
Hepatitis
Heart Murmur
Herpes
High Blood Pressure
Rheumatic Fever
Kidney Disorder
Tuberculosis
Pins/Broken Bones
Venereal Disease
Stomach / GI Disorder
Other
None of the Above
If OTHER, please explain:
INSURANCE INFORMATION
You do not need to have insurance to participate. If you are uninsured, leave this section blank
Mass Health Number
Please enter your 12 digit Masshealth
Dental Insurance (other than Masshealth)
Subscriber Name
First Last
Subscriber Address

Street Address City State / Province / Region Postal / Zip Code Country / Region
Subscriber Date of Birth
MM / DD / YYYY
Subscriber Social Security Number
Group Policy Number
Individual Policy Number
Name of Subscribers Employer
Insurance Company Phone Number
### - ### - ####
Insurance Company Address

Street Address City State / Province / Region Postal / Zip Code Country / Region
CONSENT TO PARTICIPATE
Please read the following very carefully. By checking each box you are certifying that you understand each policy and procedure. *
I understand that this consent will stay in effect for the current school year. If dental sealants are placed they may be rechecked and reapplied next year if needed.
It is the parent/guardian’s responsibility to inform the dental provider and/or the school nurse of any changes in their child’s medical information.
I understand that a copy of my child’s dental report will be given to the school nurse and/or dental liaison and that all information about my child will be kept confidential.
If I have dental insurance, I authorize my insurance carrier to be billed for any services provided.
I give permission for my child to have fillings with the use of local anesthesia, commonly called “ Novocaine.”
I understand that CMOHS, LLC may use my child’s health information for treatment, payment, health care operations, and program evaluation.
I understand that this consent will stay in effect for one school year or upon my retraction of the consent.
I have read and understand the dental program and I consent to have my child participate in CMOHS, LLC.
I understand that this form has been provided for my convenience and the enclosed information will be sent via the internet and I will receive an email confirmation.
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
Child's Name *
First Last
Parent / Guardian Signature *
Relationship to Child *
Today's Date *
MM / DD / YYYY
Please list any comments that you wish the dentist or administration to see on the date of visit:
CONTACT INFORMATION:

Dr. Mark Doherty
Commonwealth Mobile Oral Health Services, LLC
508-947-0111
info@cmohs.us

Kristen Lepine
Vineyard Smiles
508-696-0020 x14

PATIENT INFORMATION

MEDICAL INFORMATION

INSURANCE INFORMATION

CONSENT TO PARTICIPATE

By filling out the following you are consenting for your child to participate.