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2. EARLY CHILDHOOD CAVITY PREVENTION PROGRAM
   FLUORIDE VARNISH PROGRAM | 104 S. EYDER AVE., PHILLIPS, WI 54555
4. Child's First Name*
5. Child's Last Name*
6. Child's Date of Birth*
   Child's Date of Birth
8. Ethnicity*
   -- Select One --Hispanic/LatinoNon-HispanicUnknown
9. Race*
   -- Select One --WhiteBlack/African AmericanAsianAmerican Indian/Alaska NativePacific IslanderOther
10. Gender*
    -- Select One --FemaleMale
11. Telephone Number*
13. Address*
14. City*
15. State*
16. Zip*
18. Please select the school your child attends*
    -- Select One --Phillips - Elementary SchoolPhillips - High/Middle SchoolPrentice
19. Child's Teacher*
21. Does your child see a dentist regularly?*

    1. Yes
    2. No
22. Has your child seen a dentist within the past year?*

    1. Yes
    2. No
23. Dentist Name:*
25. Does your child have an allergy to Pine/Evergreen Tree Sap?*

    1. Yes
    2. No
26. Does your child have special health care needs?*

    1. Yes
    2. No
27. Does your child have Medicaid/BadgerCare?*

    1. Yes
    2. No
29. I understand that fluoride varnish helps to protect teeth from cavities. Fluoride varnish may be applied to my child’s teeth up to four times per year. After fluoride varnish application, I should not give my child crunchy, sticky, or hot foods for one day. Your child will not need to brush for six (6) hours after the application. The oral screening your child receives does not take the place of a complete dental examination by a dentist. You will receive a follow up paper after the oral screening and fluoride varnish has been applied.
31. Electronic Signature Acknowledgement*

    I wish to submit this permission form by electronic means. By signing this permission form, I certify, that my answers are correct and complete to the best of my knowledge. I give permission to bill Medicaid/BadgerCare for the services provided. I understand the questions and statements on this permission form. I understand that an electronic signature has the same legal effects and be enforced the same way as a written signature.

    1. By checking this box and typing my name below, I am electronicaly signing the fluoride varnish permission form.
33. Electronic Signature*
34. Date*
    Date
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field