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Cleaning Consent
Child's First Name:
Child's Last Name:
Your Name
Relationship to child
Phone
Email
*** Please inform the staff if a patient has had any x-rays at another dental office****
IF DUE, do we have your consent to do the following:
BITEWING/ INTRAORAL X-RAY
FLOURIDE-
PANORAMIC X RAY
Dr. Jody recommends Fluoride at each cleaning, If your insurance does NOT cover ($58 charge), Do you consent?
** Most Insurance companies cover Fluoride and Bitewing X-rays, ONCE a year. Review your dental benefits.
Any changes to your INSURANCE? If yes upload your ID CARD
Front of Card
Upload
or drag files here
Back of Card
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or drag files here
Has your child seen an Orthodontist?
Orthodontist Name:
Office Location
Any CHANGES in your child's health history since their last visit?
If YES please list
Additional Comments:
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