Thank you for submitting Grins on the Go Permission Form!

Grins On the Go Permission Form

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Please mark the FREE services you would like by checking YES below:

Parent/Guardian Permission:

By signing this permission form:

  • I grant permission for my child(ren) to receive the dental care service(s) I selected above.
  • I represent that neither I nor my child(ren) have experienced symptions of COVID-19 or have a suspected or diagnosed case of COVID-19.
  • I acknowledge the contagious nature of COVID-19 and I voluntarily assume the risk that performance of the selected service(s) by Delta Dental employees might expose my child(ren) and me to infection by Covid-19 and to resulting adverse health effects, despite Delta Dental’s efforts to mitigate that risk.
  • On behalf of my child(ren) and me, I hereby release, discharge, covenant not to sue, and hold harmless Delta Dental, its employees, management and other agents from all liabilities, claims, damages, costs and expenses resulting from acts, omissions or negligence in the performance of the selected services by Delta Dental of Idaho employees.