Smiles 4 Life Enrollment Form
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3Smiles 4 Life Enrollment Form
Questions? Please feel free to call Smiles 4 Life at (262) 896-9891
Fax forms to (262) 347-4449
Melrose Mindoro School District
Student Enrollment
Yes, please enroll my dependent.
First Name:________________________
Last:_____________________________
Middle:_____________________
Date of Birth:___________________________________
Sex:
Male
Female
Race:
White
Hispanic
Black
Asian
Native American
Other:_______________________
(Optional)
Type of Dental Insurance:
BadgerCare/Forward Health
No Insurance
Other
Parent/Guardian First Name:______________________________
Last:____________________________________
Primary/Day Phone:________________________________
E-mail:_____________________________________
Address:_____________________________________________________________________________________
City/State/Zip:_________________________________________________________________________________
Student Health History
If yes please explain, be specific.
YES
Does your dependent have any allergies? (Smiles 4 Life is Latex Free):___________________
NO
Has your dependent been diagnosed with a physical or mental disability?__________________
YES
NO
YES
NO
Does your dependent use medicine prescribed by a doctor?____________________________
Authorization
I understand that by signing this form, initial and ongoing preventative oral care treatment will be
provided for my dependent. I authorize BadgerCare/Medicaid insurance payments for services
rendered to Smiles 4 Life, Inc.
Date:___________________
Parent/Guardian Signature:________________________________
Initial Here
I have received the enclosed Notice of Privacy Practices, and I have been provided an
opportunity to review it.
It is still strongly recommended that you seek out a dental home (family dentist) for routine dental care including any follow up care
which may be recommended by this school based oral health program.
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