Enrollment Ver. 250814 charitable

School District*

School Name*

Child's Date of Birth*

Child's First Name*

Child's Last Name*

Gender Assigned at Birth*

Ethnicity

Race

Email*

Primary Phone*

Parent/Guardian*

First Middle Last

Address*

City*

ZIP Code*

Insurance Info

Type of Dental Insurance*

BadgerCare/ForwardHealth
No Insurance
Other

Type of Dental Insurance*

BadgerCare/ForwardHealth
No Insurance
Other

All students who do not have a family dentist are welcome to enroll. If you do not have BadgerCare/ForwardHealth, preventative services will be donated charitably to your student. For more information please contact Bridging Brighter Smiles.

Type of Dental Insurance*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

*Bridging Brighter Smiles does not accept private insurance. Funds made available through your FSA/HSA account may be utilized as a form of payment, please check with your carrier for specific terms and conditions

Type of Dental Insurance*

BadgerCare/ForwardHealth
Blue Cross Blue Shield
ICare
Molina
Children's Community Health Plan
United Healthcare of Wisconsin
MHS Health WI
No Insurance
Other

All students who do not have a family dentist are welcome to enroll. If you do not have BadgerCare/ForwardHealth, preventative services will be donated charitably to your student. For more information please contact Bridging Brighter Smiles.

Student Health History

Does your dependent have any allergies? (Bridging Brighter Smiles is latex free)*

Yes
No

If Yes, Please Explain

Has your dependent been diagnosed with a physical or mental disability?*

Yes
No

If Yes, Please List Here

1. Does your child need or use more medical care than other children their same age?*

Yes
No

2. Does your child have trouble doing things most other children the same age can do?*

Yes
No

3. Does your child need or get special therapy, such as physical, occupational or speech therapy?*

Yes
No

4. Does your child need counseling or treatment for behavior or emotional problems or delays in walking, talking or other activities other children their age can do?*

Yes
No

If you selected YES to any of the questions above, has the problem lasted or expected to last more than 12 months?

Yes
No

Does your dependent use medicine prescribed by a doctor?*

Yes
No

If Yes, Please List

Does your dependent require an antibiotic prior to dental procedures? (i.e. due to a heart condition).*

Yes
No

Authorization

Click here for information on dental x-rays. I authorize that new dental x-rays may be taken.

Yes
No

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.

Yes

Electronic Signature

I confirm that I am the legal guardian of the above student and understand that initial and ongoing preventative dental care treatment will be provided for my dependent. I authorize BadgerCare/Medicaid insurance payments for services rendered to be forwarded to Bridging Brighter Smiles, Inc. If in the future Medicaid requires copays, I agree to pay. I have the ability to unenroll at any time by written withdrawal of consent. I authorize a Wisconsin licensed dentist to provide my child with a dental examination at their school without a parental/guardian present unless consent is withdrawn. I understand that the exam may be done through teledentistry and without the dentist onsite at the school.

I confirm*

I Agree

First Name*

Last Name*

Date*