Beaufort Jasper EOC Head Start

Consent for Dental and Physical Services

CONSENT TO RECEIVE MEDICAL AND/OR DENTAL EXAMINATION

Child's Last Name:*
Child's Middle Name:
Child's First Name:*
Date of Birth:*
Parent's First Name:*
Parent's Middle Name:
Parent's Last Name:*
What program option are you registering for?*

Center:*

I,   ,  hereby give my consent for the child listed below to receive a medical and/or dental examination. I understand that these services are deemed necessary or advisable by Beaufort-Jasper EOC Head Start program and they will be conducted by a trained Head Start Staff or medical and dental provider contracted through Beaufort-Jasper EOC Head Start. I understand that I will be notified of my child’s test results, if additional treatment is needed.

Medical Examination (includes but not limited to: height, weight, blood pressure, hematocrit, lead, hearing, vision and additional screening if necessary)

Dental Examination (includes prophy and fluoride treatment)

This consent is valid for one year after the date signed.

I confirm that I have read and understand this form. *

----------------------------
Parent Signature
Back