I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history on behalf of my child. I have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers regarding the medical-dental history.
Should there be any change in either my child's health status or any other information I have provided, I will advise the dental hygienist.
I authorize the provider, (dental hygienist) to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment for my child. I understand this action will give my consent verbally.
I understand the information provided from or to my child's medical doctor, dentist or another health care provider may be necessary.
I give permission to the dental hygienist to correspond through a phone call, text or email communication, if necessary, with me or my child's health care provider. I am aware, although necessay precautions are in place to protect my child's personal, medical and dental information, communication through email, phone or text may not be entirely secure.