"*" indicates required fields

Student Info - Please use Legal Name

Dependent*
MM slash DD slash YYYY

Parent/Guardian Info - Please use Legal Name

Parent/Guardian*
Address*

Insurance Info

Select Insurance Type
Please click here to read Bridging Brighter Smiles Coverage Information/Fees.
I acknowledge that I have read and/or received Bridging Brighter Smile's Coverage Information/Fees.*

Student Health History

Does your dependent have any allergies? (Bridging Brighter Smiles is latex free)*
Has your dependent been diagnosed with a physical or mental disability?*
Does your dependent use medicine prescribed by a doctor?*
Does your dependent require an antibiotic prior to dental procedures? (i.e. due to a heart condition).*

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.
*
I confirm that I am the legal guardian of the above student and understand that by signing this form, initial and ongoing preventative dental care treatment will be provided for my dependent. This consent is good for two school years. I have the ability to dis-enroll at any time by written withdrawal of consent.*

Electronic Signature

I understand that by selecting "I agree" below, this constitutes a legal signature. I authorize BadgerCare/Medicaid insurance payments for services rendered to be forwarded to Bridging Brighter Smiles, Inc. I agree to pay any BadgerCare/Medicaid copays. If my dependent is not insured through BadgerCare/Medicaid insurance, I agree to pay the standard fees for services rendered (see Coverage Information) directly to Bridging Brighter Smiles, Inc.*