Child Dental Screening Consent
Please complete this form to provide consent for your child's dental screening. All information will remain confidential and is required for safe and effective care.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Relevant Medical or Dental History (e.g., allergies, current medications, previous dental issues)
*
Screening Preferences
*
Routine dental screening
Fluoride application if recommended
Dental x-rays if needed
Other (please specify below)
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you give permission for your child's photo to be taken for dental records?
*
Yes, I give permission
No, I do not give permission
Submit Consent
Should be Empty: