FAMILY FIRST HEALTH Mobile School Dentist Digital Enrollment Form

Dental Insurance Information
Dental Insurance Plan Name
Medicaid / State Insurance Plan Name
CHIP Insurance Plan Name
Private Insurance Plan Name
If other, then please explain.
Dental Insurance Subscriber/Member ID
A number on the insurance card that tells who you are. Usually 8-12 numbers or letters.
Dental Insurance Group #
A number on the insurance card that shows the health plan. Usually 5–8 numbers or letters.
Front of Dental Insurance Card

Please take/upload clear pictures of the front and back of your cards so we can read all the words and numbers.
Cancelof
Back of Dental Insurance Card

Please take/upload clear pictures of the front and back of your cards so we can read all the words and numbers.
Cancelof
Additional Dental Insurance Information

(if insurance is through parent/guardian)
Dental Insurance Subscriber's Name
(if insurance is through parent/guardian)
Dental Insurance Subscriber's Date of Birth

MonthDayYear
(if insurance is through parent/guardian)
Dental Insurance Subscriber's Social Security
(if insurance is through parent/guardian)
Dental Insurance Subscriber's Employer's Name
(if insurance is through parent/guardian)
Medical Insurance Information
Medical Insurance Name
(If none, then type "none".)
Medical Insurance Subscriber/Member ID
A number on the insurance card that tells who you are. Usually 8-12 numbers or letters.
Medical Insurance Group #
A number on the insurance card that shows the health plan. Usually 5–8 numbers or letters.
Front of Medical Insurance Card

Please take/upload clear pictures of the front and back of your cards so we can read all the words and numbers.
Cancelof
Back of Medical Insurance Card

Please take/upload clear pictures of the front and back of your cards so we can read all the words and numbers.
Cancelof

Important

Please read this carefully. Signing your name means you agree.
I give permission for my child to receive the following dental services from Family First Health during the 2026-2027 school year:
- Exam(s)
- X-rays
- Cleaning(s)
- Fluoride
- Sealants
- Oral health education
By signing below, I confirm that I am the child’s legal guardian or legally authorized to make medical decisions on their behalf, and I consent to treatment. I understand that fluoride products are used during Mobile School Dentistry events, and Family First Health cannot provide a fluoride-free environment. I understand that Family First Health will look up and bill my child’s insurance even if I don’t provide insurance details. If my child receives dental care elsewhere as well, insurance may not pay for both visits, and I may be responsible for any uncovered costs. I confirm the insurance information I provided is current, and I authorize billing for services. I have completed the registration form and understand that services are provided with care and confidentiality.
I consent
Parent/Guardian's Signature
Date

MonthDayYear
Date
Should be Empty:

Mobile School Dentist Program Registration Form

School Information

Student's Information

Parent/Guardian's Information

Dental Insurance Information

Additional Dental Insurance Information

Medical Insurance Information

Student's Health History

Important