GRANJA-KALINAWAN NATIONAL HIGH SCHOOL

Jaro Leyte

PARENT CONSENT

I, _____________________hereby willingly and voluntarily give consent for Dental

Tooth Extraction of my son/daughter ______________________in the Karen Javier Medical
Mission at Jaro, Leyte this November 16 &17,2023.
I affix my signature to give consent to routine dental care, which may include tooth
extraction during the said medical mission. I understand that removing teeth does not always
remove all the infection, if present and it may be necessary to have further treatment. I
understand the risk involved in having teeth removed that can last for an indefinite period of
time.
I understand I may need further treatment by a specialist if complications arise during or
following treatment, the cost of which is my responsibility.

_______________________________________
Parent’s Signature Over Printed Name