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Consent Form

Medical History

Child information

Name
Name
First Name
Last Name

Child's Medical History

Does your child have any medical conditions that we should be aware of?
Has your child has any surgeries or been hospitalised in the past?
Is your child being treated by a doctor at present?
Has your child had any serious or long-standing illness?
Does your child have any allergies such as latex, milk protein, peanuts, or other?
Acceptance

Consent

I give consent for Rouse Hill Smiles Dental Care to carry out a dental check-up and professional clean. I understand that the childcare staff will help correctly identify my child for the oral health practitioner. I also confirm that I have disclosed all necessary medical and personal details, allergies relevant to my child’s health. I consent to photos and videos being taken during education and dental treatment and being published on the website, social media and used in promotions. I understand I will receive a dental report and receipt once the visit is complete.

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