PLEASE PRINT IN INK 

Services Rendered By:

DENTAL EXAM

(up to a $475 value)

MUST BE RETURNED TOMORROW

NAME OF SCHOOL:____________________________________________________________________

Miles of Smiles, Ltd.

TEACHER:_____________________________________________________________________ 

GRADE: ______

137-F Radio City Dr.

COUNTY:______________________________________________________________

North Pekin, IL 61554

Dear Parent or Guardian,

309-382-6404

Miles of Smiles, Ltd. and The Illinois Department of Healthcare and Family Services have arranged for dental services for eligible children. 
These services may include an exam, cleaning, fluoride treatment and sealants (a protective coating on the chewing surfaces of back teeth). 
Licensed dentists, hygienists, and assistants will come to your child’s school with portable equipment. In order for your child to receive these 
services YOU MUST PROVIDE ALL THE INFORMATION REQUESTED BELOW AND SIGN IN THE AREA INDICATED.

YOUR CHILDS NAME:____________________________________________________________BIRTH DATE: _____/_____/_____ 

ADDRESS:_______________________________________________________________________________ GENDER: M / F

CITY/ZIP:______________________________________________________________

HOME PHONE:

________-_________-_________

DOES YOUR CHILD QUALIFY FOR FREE OR REDUCED MEALS: 

YES / NO

YES / NO

IS YOUR CHILD ENROLLED IN THE ‘Medicaid/All Kids’ PROGRAM: 

IF YES, INCLUDE YOUR CHILD’S RECIPIENT ID NUMBER: 

_____ _____ _____ _____ _____ _____ _____ _____ _____

 (9 DIGIT ID NUMBER ON BACK OF MEDI-PLAN CARD)

**Medicaid/All Kids will be billed**

IS YOUR CHILD COVERED BY PRIVATE DENTAL INSURANCE: 

YES / NO

(The dental insurance company will be billed)

If YES, please fill out ALL the insurance information below: (if incomplete, only grades K, 2nd, & 6th may be eligible for an exam)

Name of Dental Insurance Company:___________________________________________________________________________________

Dental Insurance Company Address:__________________________________________________________________________________

Dental Insurance Company plan or group number:________________________________________________________________________

Name of the Insured:______________________________________

Phone # of the Insured:_____________________________________

Address of the Insured:_____________________________________________________________________________________________

Insured Date of Birth:______________________________________

Insured ID or SS #:________________________________________

Employer:_______________________________________________

Employer Phone #:_________________________________________

Employer Address:_________________________________________________________________________________________________

Has your child had any history of, or conditions related to, any of the following: (Please circle)

Anemia:

YES / NO

Chronic Sinusitis:

YES / NO

Growth problems:

YES / NO

Seizures:

YES / NO

Asthma:

YES / NO

Diabetes:

YES / NO

Hearing:

YES / NO

Thyroid:

YES / NO

Bleeding disorders:

YES / NO

Ear aches:

YES / NO

Heart:

YES / NO

Tobacco / drug use:

YES / NO

Cancer:

YES / NO

Epilepsy:

YES / NO

Latex allergy**:

YES / NO

Allergies:

Cerebral Palsy:

YES / NO

Fainting: 

YES / NO

Pregnancy (teens):

YES / NO

Other:

YES / NO

Is your child taking any prescription and/or over the counter medications at this time? 

If yes, please list: 

What type of water does your child drink? 

__City water

__Well water

__Bottled water

 __Filtered water

IMPORTANT: PARENT/GUARDIAN SIGNATURE REQUIRED

I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving the dental treatment 
described, and allow the school nurse/ school representative and dental provider access to child’s dental record.

To the extent permitted by law, I consent to the use and disclosure of the minor child's protected health information to carry out payment 

activities in connection with this claim. I hereby authorize and direct payment of the dental benefits directly to Miles of Smiles, Ltd.

SIGNATURE:

DATE:

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