Consentimiento Tratamiento

Choose a payment source, and complete all fields below.

I agree to pay for services.

• Teeth Cleaning - Age 11 & Under - $40.00, Age 12 & older - $54.00
• Fluoride Varnish - $26.00
• Sealants (only permanent back teeth) - $32 per tooth
• SDF (silver diamine flouride) - $15 per tooth
• Therapeutic fillings - $50 per tooth

I understand if my child is not eligible for Medicaid or private insurance coverage, I am financially responsible and agree to pay for services.

• Teeth Cleaning - Age 11 & Under - $40.00, Age 12 & older - $54.00
• Fluoride Varnish - $26.00
• Sealants (only permanent back teeth) - $32 per tooth
• SDF (silver diamine flouride) - $15 per tooth
• Therapeutic fillings - $50 per tooth

I request and authorize HPS, their contracting dentists, and staff, duly licensed as Doctors of Dentistry or licensed dental hygienists, to perform any diagnostic procedures, preventive procedures or treatment procedures on my child. I understand that preventive services do not take the place of an examination by a licensed dentist.
I understand that the application of SDF (Silver diamine flouride) will cause dark staining of infected tooth structure.
I understand that dental photos may be taken for educational purposes.
I understand that if my child is not enrolled in Medicaid, I am financially responsible to HPS for services performed.
I authorize payment of Medicaid or Insurance benefits directly to HPS and their partner dentists.
I request and authorize the release of information on this form or acquired in the course of treatment for payment or referral purposes, and to all appropriate school personnel, as deemed necessary by HPS.
I give permission for communication and treatment report to be sent by email or text.
Printed name is considered legal signature.