Brighter Smiles is an oral health preventative service program. We have partnered with Auburn Public Schools to bring dental services directly to the students. Dental Days will be posted to your school calendar.
This permission slip is valid for the whole 2020-2021 school year.
Information for every child will be kept confidential.
Child First Name
Date of Birth (MM-DD-YYYY)
Already sign your child up for Dental Day but want to make a contribution?
Yes- I want to make a contribution online.
No- I wish to fill out the online permission slip for my child.
Already see a dentist twice a year? Great! This program is just an extra step in helping your child fight tooth decay. It does not replace seeing your dentist twice a year for X-rays and routine care.
Would you like preventative services for your child? Fluoride Varnish can safely be applied 4-6 times a year and can decrease further cavity development by about 38%. Applying sealants can reduce decay by up to 80%. Both fluoride varnish and sealants are safe. They are both approved by the American Dental Association and the Federal Drug Administration.
NO THANK YOU
Select services for child.
Superficial Screening ONLY
Superficial Screening & Fluoride Varnish
Cleaning (If Hygienist Deems Necessary)
Does your child see a dentist one/two times a year?
Dentist name and practice:
Does your child have private insurance? * DATA question. Examples: BlueCrossBlueSheild, Etna, etc.*
Does your child have Medicaid or CHIP? *All services are covered under Medicaid/CHIP*
A $40 contribution is suggested per child for
the whole school year
, but any amount is appreciated.
No child will be turned away.
Medicaid Dental MCNA participants all services are covered. Will you be contributing today?
Please enter the amount you wish to contribute. Thank you!
If you are having any problems with filling out this online form please call: 402-274-3993 ask for Jami Thody Brighter Smiles Coordinator.
Household / Adult Primary Contact
All information will be kept confidential.
Relationship to Participants:
Please click the calculate button :)
I would like to contribute by:
Check (Make out to SEDHD)
Cash (Send in envelope)
By signing or typing in your name below you acknowledge that your child(ren) have been signed up for dental services.
With COVID-19 causing uncertainty at this time we are taking extra precautions to keep your child and our staff safe. The Brighter Smiles team will be using personal protective equipment that consists of a clear face shield, mask, disposable gown and gloves. Also taking extra disinfecting precautions between each child like before, with having a clean area for your child to sit while conducting the clinics. If you have any questions or would like more information, please contact Jami Thody at 402-274-3993.