Ross Fishman, DMD, MS • William Love, DDS
Fishman Pediatric Dentistry / 552 Jacksonville Dr. / Jacksonville Beach Fl, 32250
I understand that the information I have given is correct and to the best of my knowledge, and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission be obtained from a parent or legal guardian before any dental services can be rendered. I give my consent to Dr. Fishman and his staff to perform such treatment, services, medication, local anesthesia and/or analgesia necessary to treat any dental/oral abnormality and/or infections.