Fluoride Varnish Application Consent Form
Please complete this form to provide your consent for a fluoride varnish application.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does the patient have any known allergies to fluoride or dental materials?
*
No
Yes
If yes, please specify allergies
Name of Parent/Guardian (if patient is a minor)
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit Consent
Submit Consent
Should be Empty: