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.

Para formulario en español haga clic aquí.

Today's Date * +

School *

Grade *

MY CHILD'S INFORMATION

First Name *

Last Name *

Middle Initial

Preferred Name

Age *

Birth date * +

Gender *

Male

Female

Home phone

Cell phone *

Email *

Home address *

Apt#

City *

Zip Code *

DENTAL INSURANCE

Choose Insurance Type *

Medicaid

Private Insurance

Other

Name of Insurance Company

Member ID number *

Policy Holder's Name *

Policy Holder's Date of Birth * +

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?

Explain

Has your child ever had any of the following medical problems? Please check each condition that applies to your child:

List allergies to medication/other

Name of child's doctor

Doctor's Phone

Date of last medical examination +

Use space below to provide additional details on your child's health. List current medications.

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.

Parent/Legal Guardian name *

Date * +

Signature *

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(318) 317 - 2800 or (972) 805-2900

Please print a copy of this for your records.

Hepatitis	Latex Allergy	Behavioral Problems	Pregnant
Asthma or Wheezing	Rheumatic Fever (Ever Had)	Hepatitis/Liver Problems	AIDS/HIV
Diabetes	Kidney Problems	Bleeding Problems/Hemophilia	Require wheelchair access
Heart Disease	Recent Dental Problems	Seizures	Cancer
Epilepsy/Seizures	Tuberculosis (TB)

MY CHILD'S INFORMATION

DENTAL INSURANCE

MEDICAL HISTORY

Terms of Service

(318) 317 - 2800 or (972) 805-2900

WWW.MILESFORSMILES.COM