Brighter Smiles

Brighter Smiles is an oral health preventative service program. We have partnered with Nebraska City Public Schools to bring dental services directly to the students. Dental Days will be posted to the school calendar.

This permission slip is valid for the whole 2020-2021 school year.

Child Information

Information for every child will be kept confidential.

Child First Name *

Last Name *

Date of Birth (MM-DD-YYYY) * +

School *

Grade *

Teacher *

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 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. *

YES PLEASE

NO THANK YOU

All students PK-4th, 7th, & 10th graders are mandatory screened once a year per DHHS Nebraska School Health Screenings section 7-004.01. These screenings will be done in the FALL semester.

Select services for child. *

Superficial Screening ONLY

Superficial Screening & Fluoride Varnish

Sealants

Cleaning (If Hygienist Deems Necessary)

Does your child see a dentist one/two times a year? *

YES

NO

Dentist name and practice:

Does your child have private insurance? * DATA question. Examples: BlueCrossBlueSheild, Etna, etc.* *

YES

NO

Does your child have Medicaid or CHIP? *All services are covered under Medicaid/CHIP* *

YES

NO

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? *

YES

NO

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: *

Parent

Guardian

Other Other

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Email Address

Please click the calculate button :)

0.00

Contribution Amount: *

I would like to contribute by: *

Check (Make out to SEDHD)

Cash (Send in envelope)

PayPal

None

By signing or typing in your name below you acknowledge that your child(ren) have been signed up for dental services. *

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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.