Child's First Name:

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Child's Last Name:

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Child's Date of Birth:

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Age:

Ethnicity

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Postcode:

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Local Authority :

Northumberland

North Tyneside

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School

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Parent with Responibility - First Name:

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Parent Last Name

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Email Address for confirmation:

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Any Additional Notes:

I have read and understood the information for parents and persons with parental responsibility

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I agree to my child having a dental check as part of the national dental survey 2023 to 2024

Please Agree

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Thank you for completing the consent form.

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This will help us evaluate this online consent process and make any improvements for next time.

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Consent form for Dentistry Survey