By signing below, I give consent for my child to participate in the preventive and restorative dentistry program conducted by the Committee for Community Outreach and Access program, known as Give Kids A Smile. To the best of my knowledge, the medical history questions on page 2 have been answered correctly and accurately. I allow my child to receive local anesthetic (numbing of the teeth), Nitrous, dental treatment, antibiotics and analgesics (Tylenol, Ibuprofen) with appropriate instructions if deemed necessary by the treating dentist. Our dental clinic will honor the rights of patients regarding their protected health information with rare exceptions that must use and disclose only as much information needed to accomplish the intended dental treatment. I also give permission for my child to be photographed while at the clinic, understanding that the photos may be used in future educational and promotional material.

By signing below, I confirm that to the best of my knowledge, the questions on this Medical History Form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform Give Kids A Smile of any changes to my child's medical status.