By signing below you:
As the legal parent/guardian, I hereby consent to the release and exchange of information, including any relevant personal health information, between the dental sealant staff, school staff, insurance carriers, the child’s dentist, applicable Coordinated Care Organization, and/or the Dental Care Organization of record. I understand that my child’s school may not supervise my child or dental staff during the time of this consented procedure. I have received a copy of “Notices of Privacy Practices.” Privacy Practices are available on the Dental3 website http://dental3.net/forms/.