• (*) indicates a required field.
  • I give permission for:

  • to bring my child(ren) to Kids Healthy Teeth for their dental care. For new Patient appointments Parent/Guardian MUST be present. Treatment to be performed includes pediatric services (examinations, cleaning, radiographs, fluoride treatment, and restorative needs as have been already fully explained to me). By signing this form I am providing informed consent and assuming financial responsibility for my child(ren) to be treated under the care of Dr. Sheryl H. Griffith and her team.

    This consent shall be effective from date to signature until revoked by parent or legal guardian.
  • Signature of Parent or Legal Guardian

    (Please use your mouse or finger on a touchscreen to sign in the box.)
  • MM slash DD slash YYYY