PLEASE COMPLETE & RETURN THIS FORM ON THE NEXT DAY OF SCHOOL 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the *PATIENT INFORMATION* section. Enter your child's name, birth date, grade, and gender. Ensure all fields are completed accurately.
3. Next, provide your contact information including phone number, teacher's name, and school details in the designated fields.
4. In the *INSURANCE INFORMATION* section, check the appropriate box for Medicaid, private dental insurance, or uninsured. Fill in any required ID numbers as needed.
5. Complete the *HEALTH HISTORY/INFORMATION* section by checking any relevant health issues and listing allergies or current medications your child may have.
6. Finally, ensure that a parent or legal guardian signs and dates the form at the bottom to authorize participation in the program.

Utilize our platform today to complete this essential form easily and efficiently!