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 2025-2026 school year:
- Exam(s)
- X-rays
- Cleaning(s)
- Fluoride
- Sealants
- Oral health education
I understand that Family First Health may 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 allow staff to share my child's medical history with Family First Health.

By checking here and 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 consent
Parent/Guardian's Signature*

Clear
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