Smile Check — Age 13 to 18

Smile Check Wants to Connect with You Virtually!

In past years, the Delaware Smile Check Program has enjoyed completing dental screenings at schools across the state and performing preventive services for students on-site. This year, however, we may not get to see everyone’s smiling face right away, as the COVID-19 pandemic has rearranged plans for back to school. If your school can’t offer in-person dental screenings at this time, don’t worry! There are still lots of things to smile about.

The Smile Check Virtual Program is being offered to students who have Medicaid or CHIP, or who do not have dental insurance. Sign up today, by completing the form below.

Contact the Bureau of Oral Health and Dental Services if you need assistance.
Phone: 302-622-4540
Email: smile_check@delaware.gov

Oral Health Education
  • Offered remotely via Zoom or your school’s virtual platform.
  • Includes age-appropriate material, including why teeth are important; nutritional counseling; how to brush, floss and prevent cavities; and how oral health relates to overall health.
Screening Assessment Survey
  • Questionnaire completed by parents/guardians that lets our professional dental team know how we can assist your child and family.
Personalized Case Management
  • Customized connections to care for each child, including urgent referrals and routine preventive treatment.
  • Your child will be matched with a dental health coordinator to personally help you access any resources you need.

 

Smile Check 4 - 13-18

Student Information

(mm/dd/yyyy)
Gender *
Race (check any that apply) *
This is a federal requirement.
Dental Insurance *
Does this child have a dentist?
You will be contacted by a Community Dental Health Coordinator after the screening assessment is reviewed, to talk about any dental concerns you have, answer questions, assist you with barriers to care, and discuss oral health concerns and recommendations.

Parent / Legal Guardian Information

Parent / Legal Guardian 1
Parent / Legal Guardian 2
What is the best way to contact you? (Check all that apply) *


By submitting this consent, I hereby certify that the above information is true and complete. This program is only available to students who have Medicaid CHIP or are uninsured. You will not be billed for any service received. Medicaid and CHIP will be billed for screening and case management. All screening results and data are strictly confidential and will only be shared with a legal guardian.

CONSENT FOR EXAMS-TESTS-TREATMENT-SERVICES-RELEASE OF HEALTH AND INSURANCE INFORMATION

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
This consent indicates that you or your child may be examined, have appropriate tests, receive treatments and/or minor procedures, receive referrals, and/or receive any other services by a person authorized by the Division of Public Health (DPH). You have reviewed the DPH policy on chaperones and discussed it with your child.
You certify that you are

CONSENT TO PARTICIPATE IN HEALTH INFORMATION EXCHANGE

Receipt of Notice of Patient Privacy Practices (Acknowledgment)

By submitting this agreement, you acknowledge the Notice of Patient Privacy Practices.

Health Information Exchange
Delaware’s Health Information Exchange Network (DHIN) allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance, and state law reporting requirements. Understand that if you go to a Delaware Health and Social Services (DHSS) or Division of Public Health (DPH) facility, staff may get a copy of health care information electronically through DHIN's connections with other health care providers.

By submitting this consent, you agree to the use and release of all health care information for treatment, payment, and health care operations among the affiliated entities of Delaware Health and Social Services, Notice of Patient Privacy Practices, as amended from time to time.

Assignment of Benefits and Medical Records Release to Delaware Health and Social Services, Division of Public Health

Submitting this consent gives authorization for the following: Any insurance benefits are to be paid directly to DHSS; the release of pertinent medical information to insurance carriers; the responsibility to pay for non-covered services; to release and hold harmless the State of Delaware, DHSS, DPH, and its agents and/or staff from any liability for any injuries suffered as a result of any exams, test, treatment, and/or services rendered; the consent to taking samples, cultures, or lab tests that are deemed necessary; the chance to correct and change information to make sure it is correct and complete; to know what information is being disclosed.

I have read this form and/or if requested, had it read to me. Any disclosure of my Protected Health Information (PHI) carries with it the potential for disclosure by the recipient, and the PHI may not be protected by the federal privacy rules.

This consent shall apply to all Division of Public Health services for a period of one year from the date of submission and can be revoked, in writing, at any time. Please note, receiving family planning services is not a prerequisite for receiving any other services offered by DPH.

Screening Assessment

Has your child received dental care by a dentist in the last 12 months? *
Does your drinking water have fluoride? *
Does your child take a fluoride supplement prescribed by a dentist or physician? *
Has your child complained about any of the following in last six months? Check all that apply.
Has your child ever had or used any of the following? Check all that apply.
Is your child anxious about going to the dentist? *
What is your child’s favorite?
Does your child do any of the following? Check all that apply.
Medical conditions can affect oral health. Does your child have any of the following?
Look in your child’s mouth. Do you or your child see any of the following?
Has your child received the HPV vaccine? About 70% of oropharyngeal cancers are caused by high-risk HPV infections. *

When does your child normally brush their teeth? Check all that apply. *
How often does your child floss their teeth? *
Are there other children or adults in the household who have not been to the dentist in 12 months? *
If yes, how many?
What type of problems would prevent you from taking your child to the dentist? Check all that apply.
Who has given you the best information about oral health (teeth and mouth)? Check all that apply.
Has your child missed any school due to dental pain? *
Does your child use toothpaste to clean their teeth? *
Does your child use any of the following? Check all that apply.
Is your child pregnant? If you answer no, skip the next question.
Is your child receiving prenatal care by a doctor?
What oral health information would you find helpful?

Like Us on Facebook!Follow us on Twitter!Subscribe to our YouTube Channel!

Delaware Health and Social Services LogoDelaware Health Mothers Logo