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Below you will find links to our Health and Consent form

A new Health and Consent form is required annually to be seen at our school-based and public health clinics. 

The form must be filled out completely, including a parent or guardian signature and date.  

The Health and Consent form is available in a PDF format to be completed and signed electronically then emailed to our office. It is also available to print then returned to our office or your child's school office.

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How To Submit an Electronic Form:

1. Click on the appropriate download link below (English or Spanish)

2. The form will automatically download for completion or printing when you click the link.
3. Open the downloaded document with the free Adobe Reader (if you don't have Adobe Reader,you can follow the link below to get it free!)
4. Fill out the entire form and save it. (Remember where you saved it!)
5. Return the form to our office via email (office@twentyteeth.org) and be sure to attach the saved form. Be sure it is e-signed if returning via email. 


You can also print, sign and mail it to the address below or fax it to us. 


*** To complete the form on your mobile device you will need the free Adobe Fill and Sign app. This FREE app can be found in your app store.

Get Adobe Acrobat