Pediatric Dental Screening Registration Form

Name *

First

Middle

Last

Child Name: *

First

Middle

Last

Layout

Birthday Month

Birthday Day

Birthday Year

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

I understand that TAHTS and TIPS are conducting dental screening as a voluntary service to the community. p>

These free consultations are only to help me guide you on the future care of your kid's dental health. These consultations are not a
substitute for my responsibility of getting proper dental care through the relevant dental specialist. No medicine will be prescribed.

I agree to hold TAHTS, TIPS, and its volunteers (including physicians) harmless and free of any liabilities, for any unintentional errors, delays, or omission,
during the whole process of this health fair.

Confirmation *
I have read the above information and understand it fully.
There is no cost for a kid’s dental screening. The screening date is 10/22/2022.

Donation to TAHTS (Enter any amount you wish to donate)
We appreciate your support.