Smile Check Onsite — Age 6 to 12

Delaware Smile Check Program

The Delaware Smile Check Program invites students to receive a dental screening at school!

  • Screenings are completed by a Delaware licensed dental hygienist during regular school hours
  • Screenings take an average of 3–5 minutes per student
  • Results are sent home to parents with resources for follow-up care
  • Children who require immediate care will be connected to a dentist for treatment
  • Students who qualify will receive an application of fluoride varnish to help fight cavities
  • Participants receive:
    • Toothbrush, toothpaste, dental floss, and a prize
    • Customized dental education
    • Guide of dental resources available in Delaware
    • Assistance with finding a dentist for the whole family and making an appointment

Be an advocate for your child’s health by signing up below!

To receive on-site services, children must:

  • Have DE Medicaid or DE Healthy Children Insurance (CHIP)
  • Have not received routine dental care within the last 7 months

Did you know?

  • Oral health is an important part of a child’s overall health and well-being.
  • Cavities can be life-threatening.
  • Healthy teeth and mouths are linked to better performance in school.

If your child is not eligible for on-site services, but you’d like assistance finding a dentist or signing up for dental insurance, please call us at 302-622-4540.

Delaware Medicaid will be billed for services. Families will not receive a bill for services provided. The dental screening does not replace the recommended 6-month preventive dental visit.

Smile Check 3 - Onsite - 6-12

Student Information

Gender *
(mm/dd/yyyy)
Race (check any that apply) *
This is a federal requirement.
Dental Insurance *
Does this child have a dentist?
Has the child been seen by a dentist in the last 6 months?

Student Health History

Please check a box for any condition your child currently has or has had in the past:

Parent / Legal Guardian Information

May we send you emails?
If we need to contact you about your child’s screening results or to help you find a dentist, what is the best way to reach you?
Best time to contact you?

Emergency Contact Information

By signing this consent, I hereby certify that the above information is true and complete. I consent to a screening and, if necessary, an application of fluoride varnish to help prevent cavities. I understand that if my child has Medicaid, the insurance will be billed for any services received. If my child does not have Medicaid, he/she can still participate at no cost to me. I consent to my child’s Body Mass Index (BMI) being recorded during this screening by use of a scale for weight and a ruler for height. All screening results and BMI data are strictly confidential.

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 various health information exchange 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 6 months? Check all that apply.
Has your child ever had or used any of the following? Check all that apply.

Look in your child’s mouth. Do you or your child see any of the following? Check all that apply.

Does your child use toothpaste to clean their teeth? *
Does your child use any of the following? Check all that apply.
What is your child’s favorite?
Does your child do any of the following? Check all that apply.
Is your child anxious about going to the dentist? *
Who has given you the best information about oral health (teeth and mouth)? Check all that apply.
How often does your child brush their teeth? *
When does your child normally brush their teeth? Check all that apply. *
How often does your child floss their teeth? *
Does an adult supervise or help your child brush or floss their teeth? *
What type of problems would prevent you from taking your child to the dentist? Check all that apply.
Medical conditions can affect oral health. Does your child have any of the following?
Has your child missed any school due to dental pain?
Are there other children or adults in the household who have not been to the dentist in 12 months?
If yes, how many?
What oral health information would you find helpful?

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