GSES Consent for Premier Community Health Mobile Dental Services

Pasco County Schools, in collaboration with Premier Community Healthcare Group, Inc (hereinafter, Premier), is providing your child an opportunity to be seen by Premier's Mobile Dental Unit. The Mobile Dental Unit provides dental assessments and cleanings, sealants, fluoride varnish and education for the students. In order for Pasco County Schools to assist with and initiate this opportunity, we need your parental consent in accordance with the Parents’ Bill of Rights (Ch. 1014, F.S.) and FERPA (20 U.S.C. 1232g). If consent is provided, Premier will be reaching out to you to schedule the visit and obtain the necessary insurance and medical information needed, along with their own consent to provide services. Premier will provide dental services to children regardless of insurance status. Pasco County Schools will not be able to view any of the information that you provide to Premier. The consent below allows Pasco County Schools to initiate this referral opportunity and to share your parental contact information with Premier.

Student Name Student Name First Last
Student ID #
Student's Date of Birth Student's Date of Birth / MM / DD YYYY
Parent/Guardian's Name Parent/Guardian's Name First Last
Parent Date of Birth
Student's Address Student's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian's Email
Parent's Cell Phone Number - if you don't have a cell phone please reach out to the school for a paper consent. Parent's Cell Phone Number - if you don't have a cell phone please reach out to the school for a paper consent. - ### - ### ####
By my electronic signature below, I am authenticating that I am the child’s parent/guardian, with the right to execute this authorization in accordance with the Parents’ Bill of Rights, and that I understand, agree, and authorize Pasco County Schools to initiate a referral for the above-referenced services and to share my contact information with Premier for the purposes of arranging a dental visit. I understand that this consent and authorization will only be in effect for the 23-24 school year, or until I revoke such consent in writing to the school nurse of my child’s school, whichever occurs first.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.