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Patient Name: DOB:Access Community Health Centers 2901 West Belt line Highway, Ste 120, Madison, WI 5371 CONSENTIMIENTO PARA TRATAMIENTO DENTAL DEL PROGRAM CELEBRATE SMILE SMR #: Index to Consent

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Obtain a copy of the Celebrate Smiles consent form

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Fill out all the required fields on the form, such as your personal information and signature

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Who needs celebrate smiles consent for?

01

Anyone participating in the Celebrate Smiles program

02

Parents or guardians of minor participants in the program

03

Medical professionals or volunteers working with the program

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What is celebrate smiles consent for?

Celebrate smiles consent is for requesting permission to use an individual's smile in promotional materials or social media posts.

Who is required to file celebrate smiles consent for?

Anyone who wants to use an individual's smile in promotional materials or social media posts is required to file celebrate smiles consent.

How to fill out celebrate smiles consent for?

To fill out celebrate smiles consent, you need to provide your contact information, details of the individual's smile you wish to use, and the purpose of use.

What is the purpose of celebrate smiles consent for?

The purpose of celebrate smiles consent is to ensure that individuals' smiles are used in promotional materials or social media posts with their permission.

What information must be reported on celebrate smiles consent for?

You must report the details of the individual's smile you wish to use, the purpose of use, and your contact information on celebrate smiles consent.

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