Dental Sealant Program

2. Parent email:
4. Please complete the full form.

   1. YES I want my child to receive SEALANTS (Please complete the whole form and submit)
   2. NO I do not want my child to receive SEALANTS (Please fill out your child's name and submit the form)
6. Child's First Name
7. Last Name
8. Gender
   -- Select One --MaleFemale
10. School
11. Teacher
12. Grade
    -- Select One --2 (Second Grade)6 (Sixth Grade)
14. Race:

    1. American Indian/Alaskan Native
    2. Native Hawaiian/Pacific Islander
    3. Black or African-American
    4. Multiple Race
    5. Asian
    6. White
    7. Other

    Please check all that apply.

15. Is your child Hispanic?
    -- Select One --YesNo
16. Has your child had any serious health problems?

    1. Yes
    2. No
17. Does your child have any of the following allergies?

    1. Acrylic
    2. Plastic
    3. Latex
19. 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.

21. Insurance

    1. Anthem Community
    2. Buckeye Health Plan
    3. Caresource
    4. Healthy Start
    5. Humana Healthy Horizons
    6. Ohio Medicaid
    7. Paramount
    8. United Healthcare Community
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

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