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PLEASE COMPLETE & RETURN THIS FORM ON THE NEXT DAY OF SCHOOL 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the *PATIENT INFORMATION* section. Enter your child's name, birth date, grade, and gender. Ensure all fields are completed accurately.
- Next, provide your contact information including phone number, teacher's name, and school details in the designated fields.
- In the *INSURANCE INFORMATION* section, check the appropriate box for Medicaid, private dental insurance, or uninsured. Fill in any required ID numbers as needed.
- Complete the *HEALTH HISTORY/INFORMATION* section by checking any relevant health issues and listing allergies or current medications your child may have.
- Finally, ensure that a parent or legal guardian signs and dates the form at the bottom to authorize participation in the program.
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