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Mobile Dental Permission

In School Dental Care

Questions? Please Call (419) 352-8402 ext. 3295

mobiledental@woodcountyohio.gov

Tell us about your child

Student Name

Student Date of Birth

Race

Ethnicity

Social Security # (for insurance)

School

Teacher

Your Name This question requires a valid email address.

Relationship to student

Address

City

Zip

Phone

Child's Medical History
Please check all that apply

Bleeding Disorder
Cancer
Anemia/Fainting
Communicable Disease
Disability- mental or physical
Other - Write In Please enter an 'other' value for this selection.

List Allergies

Current Medications

Approximate date of last dental visit

Child Insurance

Medicaid
Private
Uninsured

Medicaid Insurance

Molina Healthcare of Ohio Inc
United Healthcare Community Plan of Ohio, Inc
Other Medicaid
Medicaid # Please enter an 'other' value for this selection.
Managed Care ID # Please enter an 'other' value for this selection.

Child Has Private Insurance

Name of Insurance
ID #
Member/Social Security#

Name of Insured Parent
Date of Birth
Employer

Preventative Care or Total Care (Check Only One)