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Great Smiles Dental
3219 McHenry Ave. Suite E Modesto, CA 95350
Phone: (209)-409-8987 Fax:(209)-322-4749

​Copyright 2013. Great Smiles Dental. All rights reserved.

OFFICE HOURS
Tue to Fri: 8:00am to 6:00pm 
 Sat: 8:00 am to 3:00pm


NOTICE TO PARENTS OR LEGAL GUARDIANS


Minors who are not accompanied by their parent/s or legal guardian must present a written consent letter signed, and authorizing the companion to bring the patient.

NOTE: THE COMPANION MUST BE OF LEGAL AGE.

*The letter must include the following:

1. The complete name of companion

2. Validity of the consent letter (indicate if only for appointment date or multiple visits)

3. Attached copy of patent/s or legal guardian’s valid government issued ID (driver’s license, passport, etc.)

4. Signature with date

 *The companion must bring the following:

1. Written consent letter with signature of parent or legal guardian

2. Valid government issued ID with photo (driver’s license, passport, etc.)

NEW PATIENT FORM