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Child consent form

Consent for your child's visit.

Free for eligible kids. Up to $1,158 covered under the CDBS

Leave this blank

1Child

2Parent

3Billing

4Consent

About your child

Child first name *

Child last name *

Gender *

Date of birth *

School / centre name *

Roll call class *

Your information is handled in accordance with our Privacy Policy and the Australian Privacy Act 1988.

Pearly · mobile dental for schools & centres · hello@pearly.com.au

ADA-accredited · NSW