Please indicate if your child has had any of the following health problems (check all that apply)

I am the parent of the child named above. I give consent for my child to receive the dental screening/assessment and oral health services by an Affiliated Practice Dental Hygienist. To the best of my knowledge, the medical history questions have been answered accurately. I allow my child to receive x-­‐rays, cleaning, sealants and/or fluoride treatment that may be recommended. The services provided are subject to change depending on numerous factors, including the patient’s behavior, the amount of future work needed and time. • Preventative/Diagnostic procedures: x-­‐rays, prophylaxis (cleaning), fluoride treatment and sealants when necessary (these services will be billed to insurance) • Visual Exam I understand that the Affiliated Practice Dental Hygienist providing the care is an Arizona licensed dental hygienist and that this care does not take place of a complete examination or dental care. I understand that the hygienist will refer my child to a dentist for treatment outside the hygienist’s scope of practice, and that if my child has not received treatment, the dental hygienist may not provide further treatment.

I understand that, under the Healthy Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. PLEASE READ THE ATTACHED NOTICE OF PRIVACY PRACTICES EXPLANATION TO ENSURE YOU UNDERSTAND YOUR RIGHTS TO PRIVACY AND KEEP IT FOR YOUR RECORDS. By placing my electronic signature below, I agree that I have been informed of my NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such NOTICE OF PRIVACY PRACTICES prior to e-signing this consent. I understand my rights to the privacy of my personal information.

This office has offered to communicate using the following means of electronic communication: Email, Social Media, Videoconferencing Appendix A https://bit.ly/36hhBtw PATIENT ACKNOWLEDGMENT and AGREEMENT https://bit.ly/2NNn2tz