Dental Screening and Fluoride Varnish Consent Form

Client information

Niagara Region Public Health provides free dental services by a registered dental hygienist to children and youth 17 and under.

To receive free dental screening and fluoride varnish, sign and complete this form at least five business days before your child’s scheduled date.

1. Client information

Child's first name *This question is required.

Child's last name *This question is required.

Child's date of birth *This question is required. This question requires a valid date format of YYYY/MM/DD.

calendar

Parent / guardian's name *This question is required.

Parent / guardian's phone number *This question is required.

Parent / guardian's email *This question is required. This question requires a valid email address.

Address *This question is required.

Apt. / unit

City *This question is required.

Postal code *This question is required.