Smart Smiles Consent Form

Child’s Name

Child's Name

First Name

Last Name

Date of Birth

Age

Race/Ethnicity

Gender

Male

Female

Phone Number

Email

Home Address

City

State

Zip Code

Type of Insurance

Policy No.

Does your child currently have a dentist?

Yes

No

Dentist Name

Is your child seeing a primary care physician/pediatrician?

Yes

No

Provider Name

By signing below I consent that my child can receive a dental screening and fluoride varnish.

I agree *electronic signature required if submitting electronically*

Parent/Guardian Name

First Name

Last Name

Relationship to Child

Phone Number

Date