SMILES Form | loupbasin

LBPHD
SMILES

Loup Basin SMILES is providing an opportunity for children to receive an oral exam and fluoride varnish applications

A Public Health Dental Hygienist will be coming to your school to perform the oral exam and apply the flouride varnish.

ALL children will receive a toothbrush and an oral screening.

Birthday

Grade:

Parent/Guardian Name:

Medicaid Number (of child)

*Medicaid covers the services provided*

*Private plan insurance will not apply to services provided*

Please check the dental services you would like your child to receive: Required

Oral Exam only

Oral Exam & Flouride Varnish

OPT OUT- NO oral exam or flouride varnish

Your Signature

Select a date

Do you release the right to photograph your child in connection with the LB SMILES program by LBPHD Required

Yes

A donation is helpful in order to provide this as an ongoing service.

A $15.00 donation is suggested, but any monetary donation is appreciated.

NO child will be turned away.

Cash, Check (payable to LBPHD) or PayPal all accepted.

Child's Legal Name

*LBPHD may use such photographs with the child's name for the news releases, publicity, illustration, advertising and web content.*

Thanks for submitting!

Fluoride Varnish Facts

-Fluoride Varnish is a sticky, honey like material that is applied to the teeth with a small brush.

-Fluoride varnish can be applied 4-6 times per year, and can decrease further cavity development by about 38%

-A typical fluoride varnish application costs roughly $25.00 plus the cost of an office visit.

-Fluoride varnish is safe. It adheres to teeth once it comes in contact with saliva and is precisely applied to the teeth.

-Fluoride varnish is approved by the American Dental Association and the Federal Drug Administration (FDA)

Please fill out