Mosaic Health Community Dentistry Enrollment Form: Wayland-Cohocton Prekindergarten School
*Completion of the Dental Enrollment Form is Required Each School Year

*Our Patient Bill of Rights & Privacy Notice can be found at: https://mosaichealth.org/forms-documents. A hard copy will be provided if requested.

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I give permission for my student to participate in the school based dental program.
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Student’s First and Last Name
 *
Grade *
Teacher/Homeroom *
Name of Parent or Legal Guardian *
Relationship to Student  *
Today's Date *
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