Vineyard Smiles 2021-2022 Registration Form
The dental program is available to all students. You do not need to have insurance to participate.

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.

Our dental professionals follow all infection control recommendations made by the U.S. Centers for Disease Control and Prevention (CDC) and the Massachusetts Department of Public Health (MDPH).

We want to assure you that we are taking all necessary steps to ensure that our programs offer safe services for every student and all school personnel. It is important to note that dental professionals have always been experts in infection control. For instance, we are trained to prevent infectious diseases such as flu, HIV, hepatitis, and tuberculosis. The precautions we take every day will also help prevent the spread of the coronavirus.

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 special services and will be referred to a dental provider in your community. Referrals are dependent upon the extent of the Dental Cavities / Gum Disease and 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 will do with instruments on a model. The provider makes every effort to partner with the patient and family, making the dental visit pleasant and informative.

You do not need to have insurance to participate; however, this is not a free service. Services are provided to uninsured students at a reduced rate. Don't hesitate to get in touch with the VS Coordinator for a fee schedule.

Your child should only see one dental provider. Services provided by CMOHS, LLC may affect insurance coverage for other dental visits.
  • PATIENT INFORMATION

    Please be sure to complete all sections.
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  • MEDICAL INFORMATION

    Please fill out all sections to the best of your ability.
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  • INSURANCE INFORMATION

    You do not need to have insurance to participate.

    If you are uninsured, please select, I am uninsured and please contact Vineyard Smiles for a fee schedule. This is not a free service.
  • Please enter your 12 digit Masshealth
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  • CONSENT TO PARTICIPATE

  • 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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