Dental Informed Consent Form

Free Dental Assessments with Elite Dental

Evaluations are no-cost and only available for children ages 5-18 (Grade K-12).
The event includes:
- Comprehensive dental check-up
- Instruction on proper brushing techniques
- Evaluation to determine if additional dental care is needed
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Email
example@example.com
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Primary Phone Number
Secondary Phone Number
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Should be Empty:

Free Dental Assessments with Elite Dental