Thank you for choosing Toothbud for your child's / children's dental home. This first form only needs to be completed one time per family. All information in this form is confidential and transmitted over asecure, encrypted connection and will not be sold to any third party.
The following information applies to the main legal caregiver of the child / children
Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
Important Note: The parent or legal guardian who accompanies the child is legally responsible for payment at the time of service.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.