To Whom It May Concern:

This is to certify that I’m allowing my son/daughter __________________ to receive Fluoride

Varnish application at the School Clinic during Dental Visit

______________________

Parent/ Guardian Signature

over Printed Name

To Whom It May Concern:

This is to certify that I’m allowing my son/daughter __________________ to receive Fluoride

Varnish application at the School Clinic during Dental Visit

______________________

Parent/ Guardian Signature

over Printed Name

To Whom It May Concern:

This is to certify that I’m allowing my son/daughter __________________ to receive Fluoride

Varnish application at the School Clinic during Dental Visit

______________________

Parent/ Guardian Signature

over Printed Name

To Whom It May Concern:

This is to certify that I’m allowing my son/daughter __________________ to receive Fluoride

Varnish application at the School Clinic during Dental Visit

______________________
Parent/ Guardian Signature
over Printed Name