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Dental Sealant Permission Form

  1. Please complete the full form.
  2. Race:

    Please check all that apply.

  3. Has your child had any serious health problems?
  4. Does your child have any of the following allergies?
  5. Coverage

    No payment is required of you for this program.  However, the value of this service is more than $150 per child and we rely on insurances such as Medicaid or Healthy Start to help cover the costs.  If you child is covered by Medicaid/Health Start, please check the name of their Managed Care Plan.

  6. Insurance
  7. Leave This Blank:

  8. This field is not part of the form submission.