List names and date of birth for any children in your family that can be entered into our tooth club! They will receive a Tooth Club T-Shirt, can earn Neal Notes that can be redeemed for prizes, and they will receive invitations to our fun events!

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my/my child's medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits.