Parent or Guardian,

Your school and The Heart That Smiles Mobile Dentists have arranged for dental services for eligible children.

These services may include a dental screening/exam, cleaning, fluoride treatment and sealants (if qualified).

Licensed dentists, hygienists, assistants, and/or Public Health Dental Hygienists will come to your child’s school with portable equipment. This will also give permission for IDPH Quality Assurance Audits to be performed and providers to return to your school to recheck your child’s sealants.
In order for your child to receive these services, you must provide all the information requested in the electronic form below, For your protection, you must sign the form electronically.

Fill Out Form