Consent Form (Hmong)

Bridging Brighter Smiles, Inc. – SDF Consent Form

Yog koj muaj lu nug, hu tuaj rau peb los tau, 262-896-9891

Ntawv Tso Cai rau Silver Diamine Flouride (SDF) kho nhiav

School District*
School Name*
Qhia txog tus menyuas - Thov siv lub npe raug cai
Dependent*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Tej yam Txawv Txav
1. Cov hniav uas peb siv cov kua SDF yuav pom xim av los xim dub. Thaum nwg hloov xim tshiab dub li no lawm ces txhais hais tias cov kua no pab tus hniav to tsi muaj kab noj ntxiv lawm. Qhoj kws tsis muaj kab noj hniav yuav tsis hloov xim. Qhov xim dub no ces zoo li yog ib qho kiav txhab. Cov hniav uas tsi to yeej dawb dawb xwb tsi dub.
2. Yog peb luam ntxeej rua tug menyuam cov nqai, qhov nqai ntawv yuav zoo li xim av thiamsis tsis txhob poob siab, yuav tsi ua rau nwg mob thiab ib rau ob hnub xwb nwg yeej yuav ploj mus lawm.
3. Noj zaub mov yuav tsi qab li zaub mov tiamsi yeej yuav zoo li qub tom qab ob peb feeb.
4. oj tus menyuam yuav tsi raug txhua yam kev txawv txav no. Yog koj pom tias muaj tej yam txawv tshaj no, thov hu rau peb ntawm tus xov tooj no, 262-896-9891.
Lwm Yam Uas Yog tsis Siv SDF Kho Hniav
1. Yog koj tsi coj koj tug menyuam mus cuag kws kho hniav ces nws tug hniav to yuav phem zuj zus thiab yuav mob loj zuj zus tuaj xwb. Tej zaum tseem yuav tsi muaj hniav thiab.
2. Dhau ntawm siv cov SDF lawm ces muaj siv moov xuab zeb los nraws cov hniav uas to lawm los sis kab noj lawm, thiab looj cov hniav to, rho cov hniav uas to/kab noj lawm losis lwm yam uas koj tus kws kho hniav xav hais tias yuav pab tau koj tug menyuam.
Qhia txog Niamtxiv/Tus Saib Xyuas
*
Kuv totaub hais tias kuv tub menyuam yuav muaj kev kho hniav li ntawv no: Silver Diamine Fluoride (SDF) yuav pab kom tsis muaj kab noj hniav. SDF yog ib yam tshuaj ua kua uas muab luam rau hniav to kom tsis lwj ntxiv. Muaj tej lub sijhawm Kws Kho Hniav siv cov qua SDF no los hloov cov hmoob zuab uas lawv ib txwm siv los nraws hniav to. Siv cov kua no yooj yim thiab tsi mob npaum li yav tag los. Daim ntawv tso cai no, koj, tso cai rau cov Kws Tu Hniav siv cov kua no rau koj tug menyuam li hniav 4 zaug ntxiv. Peb yuav pab li uas peb tej kev txawj ntse thiab siv cov SDF no los pab koj tug menyuam. Tiamsi peb yuav lav tsis tau ib puas feem pua hais tias cov no yuav pab tau koj tug menyuam cov hniav to kom txhob lwj mus ntxiv. **Yog siv cov SDF no lawm es tus hniav pheej lwj tsis zoo li, koj tug menyuam yuav tau mus nraw hniav ntxiv losis yuav tau looj hniav thiaj li siv tau tus hniav to. Yog tseem muaj tej yam dabtsi yuav ua ntxiv, koj yuav tau coj koj tug menyuam mus cuag Kws Kho Hniav ntawm qhov chaw kho hniav.
Kev Tso Cai
*
Kuv totaub tias thaum kuv sau kuv lub npe rau daim ntawv no, yuav siv cov SDF los pab kuv tug menyuam. Daim ntawv sau npe yuav mus rau li kuv tus menyuam li ntawv ua twb muaj nrog Bridging Brighter Smiles lawm. Kuv twb nyeem thiab totaub txog txhua yam kev txawv txav ua siv cov SDF no. Kuv tso tso cai no yuav siv nrog kuv tus menyuam daim ntawv sau npe Bridging Brighter Smiles daim cai rau BadgerCare/Medicaid insurance them nyiam rau Bridging Brighter Smiles,Inc txoj kev soj nruam.Thiab kuv txaus siab them qhov nqis uas yog kuv feem ntawm BadgerCare/Medicaid. Yog kuv tus menyuam tsi muaj ntawv kho nhiav los ntawm BadgerCare/Medicaid insurance, kuv txaus siab yuav them tug nqi uas teem tseg rau txoj kev pab cuam zaum no.
Electronic kos npe
Kuv totaub tias thaum kuv nias “Tos Cai” rau daim ntawv no, yuav tso cai siv cov SDF los pab kuv tug menyuam. Kuv tso cai rau BadgerCare/Medicaid insurance them nyiam rau Bridging Brighter Smiles,Inc txoj kev soj nruam.Thiab kuv txaus siab them qhov nqis uas yog kuv feem ntawm BadgerCare/Medicaid. Yog kuv tus menyuam tsi muaj ntawv kho nhiav los ntawm BadgerCare/Medicaid insurance, kuv txaus siab yuav them tug nqi uas teem tseg rau txoj kev pab cuam zaum no.*
- Tos Cai
Parent/Guardian Electronic Signature*
Tub Hnub*
Office Use Only
Phone
This field is for validation purposes and should be left unchanged.

Bridging Brighter Smiles, Inc. – SDF Consent Form

Ntawv Tso Cai rau Silver Diamine Flouride (SDF) kho nhiav

Qhia txog tus menyuas - Thov siv lub npe raug cai

Tej yam Txawv Txav

Lwm Yam Uas Yog tsis Siv SDF Kho Hniav

Qhia txog Niamtxiv/Tus Saib Xyuas

Kev Tso Cai

Electronic kos npe

Office Use Only