Give Kids A Smile
Give Kids A Smile
Give Kids A Smile
Give Kids A Smile
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Health History/Consent for Treatment

Please complete this form and sign as parent or guardian. This completed form and a reservation is needed to participate. "Give Kids A Smile" provides free, comprehensive dental care – including diagnostic exams, professional cleanings, sealants, fillings, and extractions.

Referral Information
  1. Who Referred You/How Did You Hear About Us? (Identify the friend, school, church, organization):

Your Child's Information
  1. To Be Completed by Parent or Guardian – Information about your child

  2. Child's Gender

  3. Medicaid Eligible

  4. Please check all that apply to the child:
  5. Medicaid Coverage

  6. Marital Status

  7. Child Lives With
  8. IN CASE OF EMERGENCY CONTACT on the day of service at the clinic:

Medical History

  1. Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that your child may have, or medication that your child may be taking, could have an important interrelationship with the dentistry your child will receive. Thank you for answering the following questions.
  2. Is your child under a physician's care now?

  3. Has your child been hospitalized?

  4. Has your child had a major operation?

  5. Has your child had a serious neck or head injury?

  6. Is your child taking any medications, pills or drugs?

  7. Is your child allergic to any of the following:

  8. Does your child have, or have they had, any of the following?

  9. Has your child had any serious illness not listed above?

Important Information

  1. To make sure that you have read, understand, and comply with the following, we require you to click the checkbox next to each statement before the form can be submitted.
  2. I give consent for my child to participate in the preventive and restorative dentistry program conducted by the Committee for Community Outreach and Access program, known as Give Kids A Smile. To the best of my knowledge, the medical history questions have been answered correctly and accurately. I allow my child to receive local anesthetic (numbing of the teeth), dental treatment, and to be photographed while at the clinic, understanding that the photos may be used in future educational material. Our dental clinic will honor the rights of patients regarding their protected health information with rare exceptions that must use and disclose only as much information needed to accomplish the intended dental treatment.
  3. To the best of my knowledge, the questions on this Medical History Form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform Give Kids A Smile of any changes to my child's medical status.
  4. You must call for an appointment: 636-397-6453 (GKAS).

    Once you click the Submit button, a dialog box will display asking you to either Open or Save the generated Pdf form. You must print a copy of this completed consent form, sign your signature, and mail to GKAS.

    Mail completed consent form to: GKAS, 340-A Mid Rivers Mall Dr., St. Peters, MO 63376, with your signature.
Greater St. Louis Dental Society
Delta Dental
ADA - American Dental Association
Missouri Foundation for Health
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Visit for the national Give Kids A Smile program.