Please read carefully and sign. By signing this Health History & Consent form, you are giving consent to the Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic to provide any dental services and/or treatment deemed necessary for your child.
I, as the parent or guardian, authorize the Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic or individual designated by Jefferson County Health Department’s Smiles To Go Mobile Dental Clinic to act for me in any emergency, accident, or illness.
I give consent for my child to receive dental services. To the best of my knowledge, the medical history questions have been answered correctly and accurately. I allow my child to receive local anesthetic (numbing of the teeth), preventative & restorative dental treatment (including, but not limited to fillings, extractions, root canals, sealants, cleaning and fluoride), and to be photographed while at the clinic. I also acknowledge that in some rare circumstances, nitrous oxide (laughing gas) may be administered to complete treatment for my child.