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Give Kids a Smile Ohio HEALTH HISTORY AND CONSENT FORM The following health history and consent form must be filled out in its entirety, both front and back, by the parent or guardian. Please tailor
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How to fill out Give Kids a Smile:

01
Visit the Give Kids a Smile website (www.givekidsasmile.org) to learn more about the program and its objectives.
02
Locate a participating dental clinic or event in your area by using the clinic finder tool on the website.
03
Contact the dental clinic or event organizer to schedule an appointment or find out the necessary registration process.
04
Prepare the required documents, such as identification, proof of income (if applicable), and any medical history or consent forms as instructed by the dental clinic.
05
Arrive at the dental clinic or event on the scheduled date and time.
06
Provide the necessary information to the receptionist or volunteer at the registration desk.
07
Follow any additional instructions or procedures provided by the dental clinic staff.
08
Allow the dental professionals to examine and provide necessary dental services to your child, such as cleanings, fillings, extractions, or preventive care.
09
Any further recommended treatments or follow-up appointments should be discussed with the dental professionals.
10
Express your gratitude to the dental clinic staff and volunteers for their support and participation in the Give Kids a Smile program.

Who needs Give Kids a Smile:

01
Low-income families who face financial barriers to accessing dental care for their children.
02
Uninsured or underinsured children who may not have regular dental care.
03
Children who have limited access to dental services due to living in rural or underserved areas.
04
Families affected by economic hardships, such as job loss or reduced income, that struggle to afford dental care expenses.
05
Any child in need of dental services and preventive care, regardless of their family's financial or insurance status.
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Give Kids a Smile is a program designed to provide free dental care to children in need.
Dentists and dental professionals who participate in the program are required to file Give Kids a Smile forms.
To fill out Give Kids a Smile forms, dentists and dental professionals must provide the necessary information about the dental care services provided to children.
The purpose of Give Kids a Smile is to improve access to dental care for children who may not otherwise receive it.
Information such as the type of dental services provided, the number of children served, and any follow-up care needed must be reported on Give Kids a Smile forms.
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