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When the Tooth Mobiles visit your agency, the dental program staff will bring copies of these forms for patients to fill out prior to treatment. It is not necessary for you to download the forms for your patients, but they are available here for your review. Please contact the site coordinator if you have any questions about these forms.
| Dental Program Forms |
Adult Consent Form and Medical History This form needs to be completed before an exam or treatment can be provided. Treatments the program can provide include: fillings, root canals, extractions, cleanings, and dental emergency treatment We do not offer dentures or removable appliances. |
Child Consent Form and Medical History This form needs to be completed for the child and signed by a parent/guardian before an exam or treatment can be provided. Treatments the program can provide include: fillings, root canals, extractions, cleanings, and dental emergency treatment. |
| For the Patient Form This post-operative form informs the patient of the treatment received and explains any additional care that may be needed. |
For dental emergencies, please go to the nearest hospital emergency room. |