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Parent Consent for Tooth Extraction

This parent consent form allows for dental tooth extraction of a student by the Karen Javier Medical Mission at Granja-Kalinawan National High School in Jaro, Leyte on November 16-17, 2023. The parent acknowledges risks involved in extraction and understands they are responsible for any additional treatment costs if complications arise. The parent signs to give consent for routine dental care including potential tooth extraction during the medical mission.

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853 views1 page

Parent Consent for Tooth Extraction

This parent consent form allows for dental tooth extraction of a student by the Karen Javier Medical Mission at Granja-Kalinawan National High School in Jaro, Leyte on November 16-17, 2023. The parent acknowledges risks involved in extraction and understands they are responsible for any additional treatment costs if complications arise. The parent signs to give consent for routine dental care including potential tooth extraction during the medical mission.

Uploaded by

Lyn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Parent Consent

GRANJA-KALINAWAN NATIONAL HIGH SCHOOL

Jaro Leyte

PARENT CONSENT

I, _____________________hereby willingly and voluntarily give consent for Dental


Tooth Extraction of my son/daughter ______________________in the Karen Javier Medical
Mission at Jaro, Leyte this November 16 &17,2023.
I affix my signature to give consent to routine dental care, which may include tooth
extraction during the said medical mission. I understand that removing teeth does not always
remove all the infection, if present and it may be necessary to have further treatment. I
understand the risk involved in having teeth removed that can last for an indefinite period of
time.
I understand I may need further treatment by a specialist if complications arise during or
following treatment, the cost of which is my responsibility.

_______________________________________
Parent’s Signature Over Printed Name

GRANJA-KALINAWAN NATIONAL HIGH SCHOOL Jaro Leyte PARENT CONSENT I, _____________________hereby willingly and vol

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