Tooth Group 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 *

Name of Child *

First

Last

Surname of Child//

Email of Parent / Guardian *

Address of Child *

Phone number of Parent/ Guardian *

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? * *

Any other comments

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? * *

Yes
No
Please contact me Prior to treatment

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

Name of Parent/Guardian Filling The Form *

General Enquiries

School Dental Services

Tooth Group Dental Enrolment Form