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Tooth Group Dental Enrolment Form
We offer Free Adolescent Mobile Dental Services at the Schools. Please fill out the Form to either give Consent or Decline our Services for your Child.
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* Indicates required question
*
Your answer
First Name of Child
*
Your answer
Surname of Child
*
Your answer
Date of Birth of Child
*
MM
/
DD
/
YYYY
Email of Parent / Guardian
*
Your answer
Address of Child
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Your answer
Phone number of Parent/ Guardian
*
Your answer
Do you wish to give consent for your child to be seen by Tooth Group team for their free consultation including x-rays at their school?
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Yes
No
Required
Do you wish to give consent for your child to be treated for free by Tooth Group team for the necessary treatment required at their school?
*
Yes
No
Please contact me Prior to treatment
Required
Please update us regarding any Medical conditions and medications that your Child may have. Please write NIL is there is nothing to report.
*
Your answer
Any other comments
Your answer
Name of Parent/Guardian Filling The Form
*
Your answer
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