I, the undersigned, verify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my physician being contacted, if necessary, to obtain information required for my child’s dental care. I authorize the dentist to perform the diagnostic procedures that may be needed to determine the necessary treatment. I assume financial responsibility for dental services rendered for my child. Should my child be referred by Tooth Fairy Kids to any other doctor for consultation and/or treatment, I consent that medical records will be forwarded. I also consent to sharing all treatment information with my child’s other guardian(s).
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