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English Parent Consent Form

Brighter Smiles Parent Consent Form

Please fill out this form for EACH child that will be seen

First Name *
Last Name *
Gender:
Ethnicity:
Race:
Does your child visit a dentist every 6 months?
Insurance:
Please check the dental services you would like your child to receive:
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
I understand that my signature is valid for one year from the date of signature, and that I can withdraw my permission, in writing, at any time.

 

We appreciate donations to help meet the cost of services provided, however, no child will be refused services if a donation cannot be made. If your child is covered by Medicaid, services are provided at no cost.

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