Miles of Smiles, Ltd 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'NAME OF SCHOOL' and 'TEACHER' fields. Ensure you print clearly in ink for legibility.
3. Provide your child's legal name and birth date in the designated fields. This information is crucial for identification.
4. Indicate whether your child has a dentist by selecting 'YES' or 'NO'. If yes, include the dentist's name.
5. Complete the insurance section if applicable. Fill out all required details including the dental insurance company and member ID.
6. Review any medical history questions carefully, circling 'YES' or 'NO' as appropriate. This ensures your child receives safe care.
7. Finally, sign and date the form at the bottom to authorize services. Make sure to print your name clearly beneath your signature.

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