Please use the following forms for the state-wide Back to School with a Healthy Smile day on July 31, 2013.

 

 

Promotional Event Flyer
How is your office helping to promote the event?  Use this premade, editable flyer to get the word out!

Acknowledgement of Receipt of Notice of Privacy Practices
This form is for the patient or guardian to sign. It shows that you have communicated and they understand their right to privacy. 

 

Free and Low Cost Care Guide
Information on dental treatment that may be given out for future dental care. 

 

Limited Doctor/Patient Relationship - English
Limited Doctor/Patient Relationship - Spanish

This for is for the patient to sign. It shows that the patient/guardian understands that you have no responsibility for further care for this patient.

 

Notice of Privacy Practices
For the patient to sign. Tells the patient/guardian how their health information may be used and disclosed. 

Photo Permission 
For the patient to sign. Gives permission for the child's photo to be taken and used for promotion of this program. 

 

Screening Form - English
Screening Form - Spanish

For the dentists' use. Please use this form for each child that you screen. Fax a copy of each form to the ODA at 405.848.8875. Keep the original for your records.

 

Coupon to Aquarium
Give this coupon as an incentive to get people into your practice.