Thank you for submitting Grins on the Go Permission Form!

Grins On the Go Permission Form

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Student Name

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Date Of Birth

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School Name

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Gender

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Grade

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Please mark the FREE services you would like by checking YES below:

YES I want my child to get free sealants (please ﬁll in entire form, sign and return).

YES I want my child to get free ﬂuoride varnish (please ﬁll in entire form, sign and return).

Decline all services.

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* As part of our program we may return to your child’s school to check the sealants. New sealants will be applied for free at that time, if needed.

Please list any medical conditions your child has that we should know about:

Is your child taking any medications?

YES

If yes, please list:

When was your child’s last dental visit?

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Please list any allergies to food, medications, environment or other:

Parent/Guardian Permission:

By signing this permission form:

I grant permission for my child(ren) to receive the dental care service(s) I selected above.
I represent that my child(ren) have not experienced flu-like symptoms or similar illnesses.
ON BEHALF OF MY CHILD(REN) AND ME, I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND HOLD HARMLESS DELTA DENTAL, ITS EMPLOYEES, MANAGEMENT AND OTHER AGENTS FROM ALL LIABILITIES, CLAIMS, DAMAGES, COSTS AND EXPENSES RESULTING FROM ACTS, OMISSIONS ORNEGLIGENCE IN THE PERFORMANCE OF THE SELECTED SERVICES BY DELTA DENTAL OF IDAHO EMPLOYEES.

To the best of my knowledge, the health history information is correct. I authorize release of information on my child’s visit to my child’s school. I have read and agreed to all of the above:

Phone:

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Date:

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Parent or Guardian (print):

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Signature:

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Grins On the Go Permission Form

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Parent/Guardian Permission:

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