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    • Home
    • ABOUT Us
      • About
      • Meet the Team
      • Community Partners
    • Services
      • School Based Program
      • Restorative Care
      • Public Health Clinic
    • Contact Us
      • Contact Us
      • Donate Now
    • Sign Up & Forms
    • Oral Education
    • Amazon Wishlist
  • Home
  • ABOUT Us
    • About
    • Meet the Team
    • Community Partners
  • Services
    • School Based Program
    • Restorative Care
    • Public Health Clinic
  • Contact Us
    • Contact Us
    • Donate Now
  • Sign Up & Forms
  • Oral Education
  • Amazon Wishlist

Sign Up for your school clinic Today

Below you will find links to our Health and Consent form

A new Health and Consent form is required annually to be seen at our school-based and public health clinics. 


The form must be completed, including a parent or guardian's signature and date.  

The Health and Consent form is available in PDF format. You can print it and return it to our office or your child's school office.

How To Submit an Electronic Form:

1. Click on the appropriate download link below (English, Spanish or Somali)

2. When you click the link, The form will automatically download.
3. Open the downloaded document with the free Adobe Reader (if you don't have Adobe Reader, you can follow the link below to get it free!)

        *** Forms will not print properly using Google Docs ***
4. Print, sign, and return it to your child's school or mail to 903 W Center Street, STE 130, Rochester, MN 55902

Get Adobe Acrobat

Patient Form Downloads

Notice of Privacy Practices (pdf)Download
School Program Health and Consent_English (pdf)Download
School Program Health and Consent_Spanish (pdf)Download
School Program Health and Consent_Somali (pdf)Download
Office_ Health and Consent Form_English (print and return) (pdf)Download
Office_Health and Consent Form_Spanish (print and return) (pdf)Download
Office_Health and Consent Form_Somali (print and return) (pdf)Download

Tooth Times Downloads

Tooth Times V1 (pdf)

Download

Tooth Times V2 (pdf)

Download

Tooth Times V3 (pdf)

Download

Tooth Times V4 (pdf)

Download

Sliding Fee Scale Downloads

Sliding Fee Scale Income Eligibility Guidelines (pdf)Download
Sliding Fee Scale Policy_English (pdf)Download
Sliding Fee Scale Policy_Spanish (pdf)Download
Sliding Fee Scale Application _Spanish (pdf)Download
Sliding Fee Scale Application_English (pdf)Download

Children's Dental Health Services

United Way Building, 903 West Center Street Suite #130 Rochester, MN 55902 Community Action Building, 105 1st Street SE, Austin, MN 55912

(507) 529-0436

Copyright © 2019 Children's Dental Health Services - All Rights Reserved.

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