Smile Time Application

Child's Information

Parent, Guardian, or Responsible Party Information

Please list any MEDICATIONS your child is currently taking:
Please list any ALLERGIES your child has:
Has the child had any history of, or conditions related to, any of the following: [Check any/all that applies]

ADHDAIDS/HIV PositiveAsthmaBlood DisordersDiabetesHeart Murmur (requiring pre-medication)Heart Murmur (not requiring pre-medication)Heart Valve ReplacementHemophiliaHepatitisKidney ProblemLatex AllergySeizuresShunts or Artificial JointsTuberculosisOther

Please select the statement that best describes you/your child's insurance status:*

My child is covered by Virginia Medicaid/FAMIS.My child is covered by a commercial dental insurance and I would like to have their Smile TimeTM visit submitted to their insurance.My child does not have Medicaid or dental insurance; however, our family income is at 250% or below federal poverty guidelines.My child does not have Medicaid or dental Insurance, and our family’s household is 250% or above Federal Poverty Guidelines.
12-digit Medicaid ID number:
I have attached a $50 money order for the Smile TimeTM visit.I would like to pay $50 by Visa/Mastercard.
I have attached a $150 money order for the Smile TimeTM visit.I would like to pay $150 by Visa/Mastercard.
Insurance Carrier Insurance*
Insurance Carrier Phone Number*
Employer Name / Group #*
Plan / ID #*
Subscriber: Full Name*
Subscriber: Birth Date *

MonthDayYear
Relationship to Patient*

As a custodial parent or legal guardian of the child listed above, I authorize PRDC to treat the above-named patient and disclose, when requested, any and all information for any illness or injury, medical history consultation, prescriptions or treatment, and copies of all medical records. I assign or authorize direct payment to PRDC toward any medical procedures performed and authorize PRDC to file claims on my behalf. I understand that I am responsible for services not covered by my insurance plan or if my insurance is not in effect at the time of service. I understand that PRDC renders services without regard to race, creed, color, or national origin. I allow school nurse/school representatives, my child's physician, and/or the dentist of my choice to obtain dental records and radiographs. I understand my child will receive a dental treatment plan and a contact follow-up call will be made within 72 hours of the dental visit. I understand by signing this consent is valid for the entire school year.
SIGNATURE OF PATIENT OR LEGAL GUARDIAN*

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DATE

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Date
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