Please complete and return to the school office. Please note that any treatment required cannot be commenced until this form has been completed.
Has your child ever had / Currently have of the following? Please select one.
In signing this form, I acknowledge that this represents an accurate medical history. I will advise “Goldfields Teeth Express” Goldfields Family Dental of any changes to this medical history in the future. I understand that all medical details will be treated with complete professional confidentiality.
