Dental Program Medical History and Consent Form

We are collecting this information to provide your child the most appropriate dental treatment option available. To provide consent for your child to receive preventive dental services, complete the following form below:

* = Required

Child Information

Parent / Guardian Information

* Do you consent to communication by text?

* Do you consent to communication by email?

Location Information

Dental Information

* Do you have a family physician?

* Do you have a dentist?

* Does your child have dental coverage?



* Has your child ever been to the dentist?

* Has your child ever received fluoride?

Medical History

* Does your child have an allergy to colophony (pine tree sap)?

* Does your child have any known allergies?

* Does your child have diagnosed asthma?

Ensure your child has their inhaler with them at school/centre/clinic the day of the dental visit

* Does your child have any medical conditions, disability, or been hospitalized in the past year?

* Is your child taking any medications (prescribed, over-the-counter or herbal)?

* Does your child have any dental concerns?

Dental Services Consent

By checking yes and submitting this form, I am authorizing Niagara Region Public Health to provide a dental screening and fluoride varnish to my child. I have had the opportunity to have my questions answered. I understand that I may withdraw my consent at any time by contacting Niagara Region Public Health. To the best of my knowledge, the personal and medical information is correct and up to date. I give Niagara Region Public Health Dental Staff permission to collect, use and disclose personal health information from/to my physician and/or dentist for purposes related to providing these dental services.

Dental Services Consent

By checking yes and submitting this form, I am authorizing Niagara Region Public Health to provide the recommended preventive dental treatment (dental assessment, cleaning, fluoride varnish and/or dental sealants) outlined by the registered dental hygienist during the appointment to my child. I have had the opportunity to have my questions answered. I understand that I may withdraw my consent at any time by contacting Niagara Region Public Health. To the best of my knowledge, the personal and medical information is correct and up to date. I give Niagara Region Public Health Dental Staff permission to collect, use and disclose personal health information from/to my physician and/or dentist for purposes related to providing these dental services.

Dental Services Consent

Your child will only be provided with the service(s) that were recommended in their Dental Screening Report Card.

* Select the preventive dental services you would like your child to receive on the Mobile Dental Clinic according to what was recommended on their Dental Screening Report Card

By checking yes and submitting this form, I am authorizing Niagara Region Public Health to provide the recommended preventive dental treatment (dental assessment, cleaning, fluoride varnish and/or dental sealants).

COVID-19 Acknowledgement

Dental procedures increase the risk for spread of COVID-19. Our dental clinic follows the College of Dental Hygienists of Ontario guidelines to ensure the risk is minimized during dental procedures.

Parent / Legal Guardian Acknowledgement

A "legal guardian" is an individual who has been awarded legal guardianship and the authority to give or refuse consent to treatment of a child by a court of law.

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

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