I authorize Suncoast Community Health Centers, Inc., to provide dental care to my child. This dental care may include: limited dental examination, dental sealants (if applicable), fluoride varnish, prophylaxis (cleaning), and oral photos (not xrays) and a potential follow up visit in the 2nd and 3rd grade for sealant retention and sealant placement. On behalf of myself and/or the patient, I authorize the dental providers to receive payment from an insurance or other third party paer that covers the services provided to this patient. Services will be provided to all children at no out-of pocket costs to the parent. The services being offered are not a subtitute for a comprehensive dental examination by a denstist. The diagnosis of caries, soft tissue disease, oral cancer, temporomandibular joint disease (TMJ), and dentofacial malocclusions will be completed by a dentist in the context of delivering a comprehensive dental exam. Please have your child get a regular dental check up.
Signature of parent or guardian to verify the above information is true and correct.