Flagstaff Dental Enrolment Form

We offer Free Adolescent Mobile Dental Services at the Schools. Please fill out the Form to either give Consent or Decline our Services for your Child.

Name of School(Required)

Name of Child(Required)

First Last

Date of Birth of Child(Required)

Email of Parent / Guardian(Required)

Phone number of Parent/ Guardian(Required)

Address of Child

Street Address Address Line 2 City ZIP / Postal Code

Do you wish to give consent for your child to be treated for free by Tooth Group team for the necessary treatment required at their school?(Required)

Yes

Please contact me Prior to treatment

Do you wish to give consent for your child to be seen by Tooth Group team for their free consultation including x-rays at their school?(Required)

Yes

Any other comments

Please update us regarding any Medical conditions and medications that your Child may have. Please write NIL is there is nothing to report.(Required)

Name of Parent/Guardian Filling The Form(Required)

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Phone

This field is for validation purposes and should be left unchanged.