J. Ackerman Coles School

J. Ackerman Coles School
Kevin Road Scotch Plains, New Jersey 07076 Christine Cappadoccia, RN School Nurse Dear Parent/Guardian,
908 757 7555 phone [email protected] JA Coles Elementary School is pleased to share an important health-­‐care opportunity for your child. On Friday, February 1, 2013, dental offices in the area will offer free dental services for children ages 12 and younger. These services, part of the New Jersey program, Give Kids a
Smile!, include examinations, cleaning, and corrective procedures such as extractions and fillings, at no cost to you.
There are several locations in our area that are taking appointments. As a parent or guardian, you must make an appointment at your preferred location. Please do so as soon as possible, since locations fill appointment spaces quickly. If the location you are interested in is booked, please call another on the list.
These are the locations nearest our school:
Union County Wortzel Integrative Dental Care, Mountainside – 908-­‐654-­‐5151 Young Family Dentistry, Plainfield – 908-­‐205-­‐8755 Neighborhood Health Svcs., Plainfield – 908-­‐753-­‐6401 Neighborhood Health Svcs., Elizabeth – 908-­‐355-­‐4459 UMDNJ-­‐SHRP Allied Dental Ed., Scotch Plains – 908-­‐889-­‐2410 Krause Dental Care, Cranford – 908-­‐272-­‐3001 RJ Dental, Roselle – 908-­‐241-­‐6455 Dr. Norman J. Schwartz, Roselle Park – 908-­‐245-­‐7700 Eastern Dental of Union – 908-­‐964-­‐5406 Emerson School, Plainfield – 908-­‐731-­‐4201
Children cannot be seen without a parental consent form. Please complete this form and bring it with you the day of your child’s appointment. If you have any questions please call me or visit the NJ website of Give Kids a Smile, www.njda.org/gkas Sincerely,
Christine Cappadoccia RN BSN CSN
Parental Consent & Registration, Health History & Consent Form
Child’‛s Information (only one form per child)
First Name __________________________
Last Name ___________________________
Date of Birth (mm/dd/yy) ______
Dental Insurance (if any) ________________
M
Address _____________________
Daytime Phone
F
City ______________ State _______ Zip______________
_______________________________
Cell Phone _____________________
Emergency Contact _______________________________
Phone ________________________
Child’‛s Health History
Circle the appropriate answer:
Circle all that apply:
Is a physician treating your child?
YES NO
If yes, why?___________________________________
Asthma
YES
NO
Heart Murmur
YES
NO
Diabetes
YES
NO
Seizures
YES
NO
HIV/AIDS
YES
NO
Heart Disease
YES
NO
Bleeding Problems
YES
NO
Has your child been a patient in a hospital? YES NO
If yes, why?____________________________________
Does your child have any allergies?
YES NO
If yes, what? ___________________________________
Does your child take medications?
YES NO
If yes, what? ___________________________________
Is there anything else we should know about your child?
______________________________________________
______________________________________________
Has your child been seen by a dentist before? YES NO
Please explain: ___________________________________
______________________________________________
Has your child ever received dental x-rays
or radiation therapy? When? __________
YES
NO
Please explain:
________________________________
Have you already been to a Give Kids A Smile
screening?
YES
NO______
I give permission to have my child’‛s photo taken
for publications, promotional purposes, website,
media press release on behalf of Give Kids A
Smile
YES
NO
PARENT/GUARDIAN SIGNATURE
I certify that I have read and understood the above questions. The information that I have provided is correct to the best of my
knowledge. I will not hold the New Jersey Dental Association, New Jersey Dental School or any other participating sites of the Give
Kids A Smile! program or any member of the staff responsible for any errors or omissions I have made in the completion of this
form. I also authorize the doctors, dental staff and dental students to perform the necessary dental services that my child may
need including, but not limited to, cleanings, fluoride, sealants, x-rays, anesthesia, pulpotomies, extractions, and fillings.
NAME OF PARENT/GUARDIAN:
__________________________________________
SIGNATURE:
__________________________________________ DATE: ________________
9/18/2008
H
P oja de Consentimiento, Registracion, y Historia Medica
Informacion del Niños (solamente una hoja por niño)
Primer Nombre __________________________
Fecha de Nacimiento (mm/dd/yy) ______
Direccion _____________________
Numero de Telefono
M
Apellido ___________________________
F
Seguro Dental
________________
Ciudad ______________ Estado _______ Codigo______________
_______________________________
Contacto de Emergencia _______________________________
Numero de Cellular ________________
Numero de Telefono _________________
Historia Medico del Niño
Marque lo apropriado:
Marque lo apropriado:
Su niño esta recibiendo tratamiento de un medico? SI NO
Si, porque?___________________________________
Asthma
SI
NO
Soplo de Corazon
SI
NO
Diabetis
SI
NO
Convulsiones
SI
NO
VIH/SIDA
SI
NO
Enfermedad del Corazon
SI
NO
Problemas de Sangramiento
SI
NO
Ha sido su niño un paciente en un hospital?
SI NO
Si, porque?____________________________________
Su niño padece de alergias?
SI NO
Si, de que? ___________________________________
Esta tomando medicamentos su niño?
SI NO
Si, que medicamento? ______________________________
Hay alguna otra informacion que debemos de saber de su niño?
______________________________________________
______________________________________________
______________________________________________
Ha visitado el niño a un dentista anteriormente?
SI NO
Por favor explique: ________________________________
______________________________________________
______________________________________________
Por favor explique:
________________________________
Has venido anteriormente para alguna actividad
dental?
SI
NO______
Yo autorizo que mi hijo(a) puede tomar fotos
para publicaciones, propositos promocionales,
para el Internet, o comunicado de prensa de
Sonrisas para Niños.
SI
NO
FIRMA DE PADRE/GUARDIAN
Yo certifico que yo he leido y entendido las preguntas de esta forma. La informacion que yo he dado es correcta de acuerdo a mi
entendimiento. No pondre en responsabilidad a la Asociacion Dental de Nueva Jersey, a La Escuela Dental de Nueva Jersey , o
cualquier facultad por cualquier error o omisiones que yo haya hecho cuando llene la informacion de esta forma. oY o autorizo a
los dentistas y estudiantes dentales que hagan todo servicio dental que mi niñ
oo necesite, incluyendo, pero no limitado a, limpiezas,
floruro, sellos dentales, radiografias, anestesias, pulpotomias, extracciones, y empastes.
NOMBRE DEL PADRE/GUARDIAN:
FIRMA:
__________________________________________
__________________________________________
12/29/2005
FECHA:
________________