Consent for Dental Treatment / Dental Care for Minor Children

  • Dr. Ross Fishman DMD, MS, PA
    552 Jacksonville Drive Jacksonville Beach, FL 32250
    Phone: (904)247-4097 Fax: (904)247-8495



  • Date Format: MM slash DD slash YYYY
  • I do hereby consent to any dental care/treatment determined necessary by Dr. Ross Fishman/Fishman Pediatric Dentistry.
    I understand that I will be financially responsible for any dental care/treatment provide by Dr. Fishman and/or staff.

  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 01 to 12.
  • Please enter a number from 20 to 35.
  • Please enter a number from 000 to 9999.