Mobile Dental Clinic Consent Form

Client information

Niagara’s Mobile Dental Clinic visits your child’s school to provide FREE dental services. A registered dental hygienist recently screened your child’s teeth at school. This screening does not replace your child’s regular visit to your family dentist.

ONLY complete this form if you want your child to receive the recommended free dental services by the date listed on the Dental Screening Report Card.

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 first name *This question is required.

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

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

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

Client's current home address *This question is required.

Apt. / unit

City *This question is required.

Postal code *This question is required.