Bridging Brighter Smiles Inc. Enrollment Form

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Bridging Brighter Smiles Inc. Enrollment Form

  • Student Info

  • Date Format: MM slash DD slash YYYY
  • Parent/Guardian Info

  • Insurance Info

  • Please click here to read Bridging Brighter Smiles Coverage Information/Fees.
  • Student Health History

  • Authorization

  • Please click here to read Bridging Brighter Smiles, Inc.’s Notice of Privacy Practices. I acknowledge that I have read and understand the Notice of Privacy Practices. I understand that I may get a copy of the Notice of Privacy Practices by visiting the Bridging Brighter Smiles, Inc.’s website at http://bridgingbrightersmiles.org/forms/, or from contacting the visit coordinator at any school location Bridging Brighter Smiles provides care.
  • Electronic Signature

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