KLINIK PERGIGIAN A DENTAL (SIBLIFE SDN.

BHD)
A-1-13, FIRST FLOOR BLOCK A, DATARAN
PUCHONG UTAMA, JALAN PU 7/1, TAMAN TEL: 03 - 8090 9205
PUCHONG UTAMA, 47140 PUCHONG
H/P: 011 - 3939 0989
EMAIL: puchongutamadentalclinic@gmail.com 0989
Dev Dharshaan
NAME :
MYKID NUMBER : 190318-14-1197
PHONE NUMBER (PARENT) : )12-2181053

DENTAL CHECK-UP (for Clinic use)

Filling FOR TREATMENT Extraction

55/54/53/52/51 61/62/63/64/65 55/54/53/52/51 61/62/63/64/65

85/84/83/82/81 71/72/73/74/75 85/84/83/82/81 71/72/73/74/75

Others : _______________________________________________________

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Dr Amirah Fahimah
MDC :6834

CONSENT (Parent please fill this below)

Pavithrah
I ___________________________ as parent or legal guardian,
Phone number 2-2181053
:_01________________ (Authorize / Not Authorize)
Dev Dharshaan
____________________________ (child’s name) to do a check-up and treatments
done by doctor Amirah Fahimah in A Dental Clinic.

___________________________

(Parents Signature)