1. I am the legal guardian of the child. I have read and understand the information on this form. This form is to obtain my consent for dental treatment for my child. By signing this electrnic consent form, I give permission for my child to receive dental treatment from the University of Detroit Mercy School of Dentistry's Titan For Teeth Mobile Clinic (TFTMC).
2. I understand that these services can be obtained at the office of my child’s dentist rather than at the TFTMC and may affect benefits that my child receives from private insurance, a state or federal program, or other third-party provider of dental benefits.
3. I have answered every question above completely and accurately. I will inform the TFTMC of any change in my child’s health and/or medications.
4. I understand that the TFTMC will bill my child’s private insurance or Medicaid if available and that I will be required to provide my insurance information to receive the services.
**If your child does not have dental insurance, please contact the Program Manager
at 313-355-0390 for additional options**