Newberg Kids' Dentist Introduction Page 5

Newberg K ids’ D entist

Dear P arents/Caregivers,

We l ove c elebrating t he g reat a ccomplishments o f c hildren. F rom t ime t o t ime w e i nclude c linic p hotos i n o ur N o C avity C lub,

Facebook p age, a nd p romotional m aterials. I n h onor o f y our c hild’s a ccomplishments, m ay w e h ave y our p ermission t o i nclude

their p hoto a s p art o f o ur p ractice p romotions?

Please s ign t his c onsent f orm a nd r eturn t o N ewberg K ids’ D entist. W e a re h appy t o p rovide a c opy f or y our r ecords a s w ell.

I, _ _________________________________________________, a m t he p arent/guardian o f

_______________________________________________ a nd I w ill a llow N ewberg K ids’ D entist t o d isplay m y c hild’s

photograph i n h onor o f h is/her g reat a ccomplishments.

Thank y ou f or a llowing u s t o c elebrate y our c hild’s e xciting d ental a ccomplishments!

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Parent category: Medical