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Vftl.iH #Hlt"tr fiA|li ffi#fi*ilt$ AfrldTAL *AR AT S#${*ffi*- Afdfi !T lS A*$S|-[-5THIY F*fE to you for children covered by Medicaid. We also accept dental insurance and we can even help if you don't have any insurance at all. lf your child has a dentist you should continue to arrange dental care through that provider. lf you have questions, please call us at i??! ef?-*ffiftfi,

Your Name:

Relation to Student:

Student Name:

Student Date of Birth: Track:

Phone:
(

/_

Grade:_
Address: Check 0ne:

2ndPhone:(_)
City:

Zip:_

Email:

qliro has Medicaid

Child has Private lnsurance

cn"o

is Uninsured

Enter Ghild's l0-Digit Medicaid # Below

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"yES' 0B "1't0" 0R L|ST,)
N0
Surgeries

HEALTH HtSToRy (C|BCLE

PTEASE N0nFY US 0F ANY MEDIGAT HISToRY CHAIIGES.

N0
Heart Problems

Kidney

Problems YES

Blood Disorder
Latex Allergy

Allergies

Liver Problems

Medications

Other Conditions

authorize Big Smiles Kentucky, PSC to provide dental care which may include dental exams, x-rays, cleanings, fluoride, sealants, fillings, crowns, baby teeth root canals and simple extractions of baby teeth at school without my presence unless I withdraw this consent. Services shall be provided by a state licensed general dentist. I authorize and direct Big Smiles Kentucky, PSC to bill and collect payment from any Medicaid, insurance or other third pafi payer that covers the services provided to this patient, which shall be applied to the patient's benefits. lf there will be cost to me, then I will be called first to approve or decline, I acknowledge receiving a notice of privacy practices attached to this consent form.
I

SIGN HERE:

DATEI

KY'GENEB.OO]

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