HYGIENE SERVICES INFORMED CONSENT PATIENT NAME* First Last Your child is scheduled to have the one or more of the following services rendered: Oral Examination, Dental Prophylaxis/Cleaning, Intraoral X-rays, and/or Fluoride Application. By signing this document I give consent to Dr. Diaz to render the above mentioned services unless otherwise declined below. (Parent/ Legal Guardian Signature)*Date* MM slash DD slash YYYY If you choose to decline topical fluoride / varnish and / or diagnostic dental x-rays, you will need to notify the office while checking in for your appointment.PhoneThis field is for validation purposes and should be left unchanged.
