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. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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