Child Consent Form

Please complete this form before your child's dental visit. All fields marked * are required. Takes about 4 minutes.

About your child

Child first name

Child last name

Gender

Date of birth

School name

Roll call class

Parent / guardian

First name

Last name

Phone

Billing & rebate

How will your child's visit be covered?

Dental & medical history

Last dentist visit

Dental habits

Current medications

Allergies / adverse drug reactions

Medical practitioner name

Medical practitioner phone

Consent declaration

By signing below, I consent to my child receiving a dental check-up, clean and any treatment Pearly's dentist deems necessary. I confirm all information provided above is accurate to the best of my knowledge.

Signature (type your full name)

Date signed

Your information is handled in accordance with our Privacy Policy and the Australian Privacy Act 1988.