Kinston Community Health Center School Based Oral Health Program Registration Packet (English)
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    The Kinston Community Health Center Junius Rose Dental Clinic, in partnership with Lenoir County Public Schools, is pleased to announce that your child can receive the following dental services at school : •Dental Exam and Diagnosis •Dental Cleaning •Dental X-Rays •Dental Sealants •Fluoride Treatments •Oral Hygiene Instructions

    DENTAL PROGRAM DETAILS 

    •Services are provided by licensed dentists, licensed hygienists and certified dental assistants. In some cases, dental students may accompany the dental professionals to provide educational and preventive services.

    •Students will receive oral health screenings, complete dental exams, cleanings, fluoride treatment, and oral hygiene instructions by the dental provider. Students will also receive x-rays as needed. Dental sealants will be placed as indicated. Following the visit, students will receive a dental report card which will be sent home. This report card will explain the treatment completed. In addition, it will explain if your student needs to be seen for further treatment. After the dental visit, a member of our dental team will be in contact to schedule an appointment at our main dental clinic.

    •Some patients may need to be seen for specialty services and will be referred to a dental provider in your community. Referrals are dependent upon the extent of the student’s dental needs as well as the behavior.

    •Informed consent indicates your awareness of sufficient information to allow you to make an informed personal choice concerning the patient’s dental treatment. Most patients do not encounter any difficulties with their treatment. If the patient indicates any resistance to the dental procedure, we will discontinue the treatment.

    •The Tell-Show-Do technique is often used to gain the cooperation and confidence of the dental patient. The dental provider explains what they are going to do and then shows what they are going to do. The provider makes every effort to be a partner in care with the patient and family, making the dental visit pleasant and informative.

    •This dental program is available to all students who DO NOT have a regular dentist. If your student has a dentist, please be sure they continue to see their dentist regularly

    DENTAL COVERAGE INFORMATION

    Services provided by the mobile dental program will affect coverage for other dental visits. If you have dental insurance or Medicaid, dental services will be billed directly. If your child does not have dental insurance, it is the parent’s responsibility to speak to a representative of Kinston Community Health Center to apply for the Slide Fee Discount Program.

     CONSENT TO PARTICIPATE

    IF YOU AGREE TO HAVE YOUR STUDENT PARTICIPATE , PLEASE CLICK "YES" AND  ENTER ALL REQUESTED INFORMATION TO REGISTER YOUR STUDENT FOR THE DENTAL PROGRAM BELOW.

    Please note: If your child already has a dentist and you DO NOT want to transfer to this mobile clinic, please DO NOT proceed with this form. Please be sure your child continues to see their dentist regularly. Thank you.

  • Date of Birth*
     - -
  • Relationship to Student:*
  • Clear
  • Date*
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  • Kinston Community Health Center School Based Oral Health Program Registration Form

    We, the staff at the Kinston Community Health Center are glad you chose the Junius Rose Dental Clinic to be your student's dental home. Prior to your student being seen as a patient, please complete all the fields below.
  • Student Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Student Ethnicity*
  • Format: (000) 000-0000.
  • Do you give permission to receive communication from our office by phone, email or text message?*
  • Parent/Guardian Preferred Language*
  • Has your child been to the dentist in the past year?*
  • Patient Medical Information

    Patient Medical Information

    Please read and complete all sections.
  • Does your child receive routine medical checkups?*
  • Are their immunizations up to date?*

  • Physician Name/Office: *
    Physician Address:  
    Physician Phone:    

  • Is your child currently under the care of a physician?*
  • Rows
  • Rows
  • Does your child need antibiotics before dental treatment*
  • Does your child take any medication*
  • Does your child have any of the following?*
  • Has your child ever had any surgeries or hospitalizations?*
  • Does your child have any food or medication allergies?*
  • Please check which allergies your child has*

  • Dental Insurance Information

    Please complete the following information regarding your child's current dental insurance
  • Does your child have dental coverage?*
  • Please check which dental coverage your child has:*
  • Since your child does not have dental coverage, are you interested in applying for the Slide Fee Discount Program

  • Dental Insurance Plan Name: *  
    Plan Subscriber Name:  *
    Plan Subscriber Date of Birth: Pick a Date*
    Dental Policy Number:   *   

  • Clear

  • Consent

    Please read the following and sign to give consent for your child to be seen for dental treatment.

  • •I understand that this consent will stay in effect for the current school year. I agree that the above information is accurate and complete to the best of my knowledge. I will not hold the school, the provider, staff or Kinston Community Health Center responsible for any errors or omissions I may have made in the completion of this form. I agree that it is my responsibility as the parent/guardian’s responsibility to notify the provider, staff and/or the school nurse of any changes in my child’s health information.

    •I understand that a copy of my child’s dental treatment and exam findings will be given to the school nurse or designated oral health person and that all information will be kept confidential.

    •I authorize Kinston Community Health Center to file the patient’s insurance and for the plan to pay for any services provided.

    • I have been provided a copy of the Notice of Privacy Practices(available to print at the end of the registration).

    •I understand this program may only use my child’s health information for treatment, payment, health care operations, and program evaluation.

    •I give consent for my student to have preventive services completed at the school oral health program including exam, cleaning, fluoride, x-rays, and dental sealants placed, if indicated. I understand that I will be notified of the findings from the dental exam. If further dental treatment is needed, my child will need to be seen as a patient at the Kinston Community Health Center main dental clinic.

    •I have read and completely understand the dental program and I give permission to have my child participate.

  • Clear

  • KINSTON COMMUNITY HEALTH CENTER, INC. PATIENT DEMOGRAPHIC FORM

    Kinston Community Health Center, Inc. is a Federally Qualified Health Center (FQHC). We receive federal grant funds that support the provision of care to our uninsured and underinsured patients. We are required to collect and report the information on this form annually for every patient that we serve. The responses on this form are aggregated and no one is ever able to identify your individual responses in our report. This information is not provided to any person, agency, or organization other than our federal grantor agency. This information is always kept confidential .
  • Are you homeless?*
  • If you answered “Yes” please tell check the best option that applies to you*
  • Are you a migrant farmworker? *Answer Yes if the following is true: You or a member or of your family with whom you reside moved in the past two years to another area (established a temporary home)in order to work mainly in agriculture.*
  • Are you a seasonal farmworker? *Answer "Yes" if the following is true: You or a member or of your family with whom you reside worked in the past two years primarily in agriculture without moving from your home.*
  • Is it difficult for you to speak, read, or write in English? Please remember, you may ask for an interpreter at any time during your visit.*
  • Do you live in public housing?*
  • If you answered “Yes”, please check the best option that applies to you:
  • Are you a Veteran?
  • Do you have insurance, Medicaid, or Medicare? Check all that apply.*
  • What is your family's total annual income? *This information is kept confidential and is used to determine if you are eligible for additional discounts.*
  • Clear

  • HIPAA – AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INDIVIDUALS FAMILY MEMBERS

    In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your healthcare provider or staff of Kinston Community Health Center to discuss your condition with members of your family of if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.
  • Please check one of the following:*
  • Do you need to add another individual
  • Do you need to add another individual?
  • Clear

  • Contact Methods

  • Kinston Community Health Center, Inc. is allowed to leave voicemails/text messages with the telephone numbers on the patient registration form regarding patient information.
  • For email communication, I understand that if this email is not sent in an encrypted manner, there is a risk it could be accessed inappropriately. I still elect to receive email communication:
  • Clear

  • Acknowledgment of Receipt of Notice of Privacy Practices, Patient Rights & Responsibilities, and Patient Bill of Rights

  • Clear
  •  
  • Should be Empty: