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  • More
    • 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
  • 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

Sign Up for your school clinic Online 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 filled out completely, including a parent or guardian signature and date.  

The Health and Consent form is available in a PDF format to be completed and signed electronically then emailed to our office. It is also available to print then returned to our office or your child's school office.

How To Submit an Electronic Form:

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

2. The form will automatically download for completion or printing when you click the link.
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!)
4. Fill out the entire form and save it. (Remember where you saved it!)
5. Return the form to our office via email (office@twentyteeth.org) and be sure to attach the saved form. Be sure it is e-signed if returning via email. 


You can also print, sign and mail it to the address below or fax it to us. 


*** To complete the form on your mobile device you will need the free Adobe Fill and Sign app. This FREE app can be found in your app store.

Get Adobe Acrobat

Patient Form Downloads

Notice of Privacy Practices (pdf)Download
COVID19 Risk Form_English (print and return) (pdf)Download
COVID19 Risk Form_Spanish (print and return) (pdf)Download
COVID19 Risk Form_Somali (print and return) (pdf)Download
School Program_ Health and Consent English (submit electronically or print and return) (pdf)Download
School Program_Health and Consent Spanish (submit electronically or print and return) (pdf)Download
School Program_Health and Consent Somali (submit electronically or print and return) (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

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 111 Main Street Suite#204 Austin, MN 55912

(507) 529-0436

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

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