We are excited about providing your child with excellent dental care at school in the Miles for Smiles mobile unit. To enroll in Miles for Smiles, complete the form below. If you are currently happy under the care of a dentist, we encourage you to continue with your current provider. If you want to utilize our services, please fill out and submit this form.
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MY CHILD'S INFORMATION

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Gender *

DENTAL INSURANCE

Choose Insurance Type *
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MEDICAL HISTORY

The following information will help us provide the best-possible dental care tailored to your child. Dental and Medical history is important for safe dental examination and treatment. Medical questions must be answered before treatment. Are there any existing dental issues we should address at the first visit?
Has your child ever had any of the following medical problems? Please check each condition that applies to your child:
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Terms of Service

I hereby authorize the Miles for Smiles mobile dental program to use or disclose any necessary patient health information (PHI) in order to carry out treatment, payment activities, and healthcare operations, as fully described in our Notice of Privacy Practices. I understand also that upon request I will receive a copy of the Notice of Privacy Policies as prescribed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).I am the parent or guardianof the above-named child and I hereby give Dr.Jeremy Simms Alexander, P.C.(provider) and/or Miles for Smiles, LLC Associates permission to treat my child with cleaning, exam, X-rays, sealants, and fluoride treatment and, if cavities are found, to treat these. Furthermore, I give Dr. Alexander and/or his Associates permission to use local anesthesia to numb for my child's comfort. If needed, I give Dr. Alexander and/or his Associates permission to perform dental extractions (pulling teeth). In addition, I give Dr. Alexander and/or his Associates permission to see my child again in approximately 6 months for cleaning, exam, X-rays and any treatment needed. This authorization will remain in effect until cancelled in writing by me.I understand that photographs of my child may be taken for promotional and/ormarketing purposes and will notify the school if I do not wish to have my child photographed.

I hereby authorize and give consent for my child to be seen by and to receive dental services from the Mobile Dental Unit. I understand that these services will be provided at my child’s school during school hours. I further acknowledge and agree that the dental services provided to my child are provided by the Mobile Dental Unit only and not by the School Board or any employees of the School Board. I further understand that although employees of the School Board may facilitate my child’s visit to the Mobile Dental Unit, no dental services are performed by the School Board and I release the School Board for any claims or damages arising out of or in any way related to the dental services provided to my child during my child’s visit to the Mobile Dental Unit. I further grant the School Board permission and authority to share my child’s personally identifiable information with the Mobile Dental Unit as necessary for my child to participate in the program.

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(318) 317 - 2800 or (866) 308 - 8370

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