Tooth Group Dental Enrolment Form

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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.

First Name of Child *

Surname of Child *

Date of Birth of Child *

YYYY

Email of Parent / Guardian *

Address of Child *

Phone number of Parent/ Guardian *

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? *

Yes

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

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. *

Any other comments

Name of Parent/Guardian Filling The Form *

Submit

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