Dental Public Health Preventive Dental Services Consent Form

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Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact Dental Public Health toll free at 1-866-368-5460.

Identification

Enter the contact information for the parent or guardian that is the student's primary caregiver in the fields below.

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

Relationship to the Student

If another parent or guardian can be notified, please fill in the fields below. To add additional parents/guardians, click the Add button below.

Parent/Guardian
	First Name Last Name Relationship to the Student First Preferred Phone Number for Contact For example 902-555-5555 Second Preferred Phone Number for Contact For example 902-555-5555 Email Can we reach out to this contact if we are unable to connect with the primary contact?	Item weight

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