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Student Medical History
2025-2026
Student Information/Permission
Student Name
Grade
Child's School
Teacher
Address
City
State
Zip code
Date of Birth:
Sex
Race
Ethnicity
Name of Legal Guardian
Relationship to Student
Email
Phone
Address if different than student's
Emergency Contact
Phone
Student’s Insurance
If private insurance company, please list
Subscriber’s name
Employer
Date Of Birth
Insurance Address
Student’s or Subscriber’s ID and Group# (HUSKY ID # from gray Connect card)
Please attach a copy of your dental insurance card (front and back) Most insurance covers cleanings one per 6 months, please check your next appointment date with your provider.
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I give permission for my child to be treated in the school and receive services deemed necessary by the dental staff of Brooker Memorial. This includes Dental Cleanings, Oral Health Screening, Fluoride and application of Sealants.
I certify that the health information provided is accurate to the best of my knowledge. I understand that providing incorrect information can be dangerous to the student’s health.
I agree that messages can be left for me on the telephone number provided in the Student Information section of this form.
I agree to ensure that my child receives any follow-up treatment outlined by the dental hygienist or dentist.
If applicable, Release of Information and Payment Authorization: I authorize the release of any medical or other information necessary to process my child’s insurance claim. I also authorize payment of insurance dental benefits to Brooker Memorial for services provided.
Authorization for Exchange of Health & Education Information: I hereby authorize Brooker Memorial to exchange health and education records with my child’s school district for the purpose of providing care and treatment to my child.
This authorization is valid while my child is enrolled in the school district. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Educational Rights and Privacy Act. I also understand if I refuse to sign, such refusal will not interfere with my child’s ability to obtain dental care. I agree that a copy of this authorization is as valid as the original.
I hereby authorize Brooker Memorial to communicate with my child’s dentist if I have listed him/her on this form. My child’s dentist may be notified by Brooker Memorial about needed follow up care or other relevant dental information, including date of their school visit with Brooker’s hygienist (for coordination of treatment and billing)
I give permission for Brooker Memorial to use my child’s name and/or photograph(s) for publicity purposes, including printed publications, internal bulletin boards, Facebook, Brooker website, Foundation For Community Health publications and other social or electronics media. I understand that no compensation or other remuneration will be given for use of any photo or information used.
HIPPA Omnibus Notice of Privacy Practices: This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your Protected Health Information (PHI) to carry out Treatment, Payment or Health Care Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. Please contact us if you would like a copy or you may access a copy at
www.brookermemorial.org
By signing below, I understand and acknowledge the following: I have read and understand this consent.
NAME OF LEGAL GUARDIAN
Signature
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Signature Pad
Date
Student Information
Is the student allergic to or has he/she had a reaction to:
Any foods
Any medicines (Penicillin or other antibiotic)
Latex
Local Anesthetics
Please explain any allergies
Has the student had any serious injuries or sports-related injuries?
Has the student ever been hospitalized overnight?
Has the student had any surgery?
Is the student taking any medication now?
If yes, please list
Who takes care of the child at home?
Does the student have any heart problems, such as a heart murmur or congenital heart defects?
If yes, is an antibiotic needed prior to dental treatment?
Has there been any change in the student’s health during the past year?
Is the student currently seeing a physician for any problems?
Does the student have any behavior or learning problems?
Physician’s Name
Physician’s Phone
Physician’s Address
Date of Last Physical Examination
Dental History
Is this the student's first dental visit?
Name of Family Dentist Seen
Last Visit
Dentist's Address
Has the student ever been seen at the Brooker Memorial Dental Center?
Was the student seen in the school dental program in prior years?
Has the student had any of the following illnesses or conditions?
ADHD / ADD
Hepatitis or Liver Problems
Anemia or blood disorders
Mental illness/depression
Asthma or Breathing Problems
Rheumatic fever or heart disease
Autism
Seizures or Fainting
Bladder or kidney infections
Tuberculosis
Cancer
Thyroid disease
Diabetes
Ulcer/digestive problems
Endocrine Gland disease
Hives or Skin Rash
Birth Defect or Disability
AIDS/HIV
Blood Transfusion
Does the student have any disease, condition or problem not listed above? If yes, please explain
Other Notes or Information
Your First Name
Your Last Name
Your Date Of Birth
Patient/Legal Guardian Signature
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Signature Pad
Date
Date Of Birth
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