Brace Bus Consent Form
Submit
I, the undersigned,
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First Name
Last Name
the parent and/or guardian of
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First Name
Last Name
hereby allow, authorize and consent for my child to ride the BRACE BUS provided by Carter Orthodontics. The undersigned agrees/consents for the Carter Orthodontic employee driving the BRACE BUS to pick up my child from school for the purpose of an appointment and return to school. The undersigned agrees to sign a consent authorizing the school to release my child to Carter Orthodontics.
This request for transportation is valid for the school year August
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through May
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Please read carefully and Initial the following:
BRACE BUS operates from September until the end of April.
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Carter Orthodontics and/or the operator of the BRACE BUS shall have the exclusive right to make the decision whether my child shall be permitted to ride the BRACE BUS. Any misbehavior or misconduct could result in my child not being permitted to ride the BRACE BUS
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On BRACE BUS appointment days please PACK A LUNCH, as appointments may coincide with school lunch times.
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Your child’s appointment will be scheduled at certain time, however for efficiency he/she will be picked up and returned to school between the hours of 8:30 AM to 12:00 PM.Note that appointment time will not indicate pick-up and return times for your child
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If you are aware of circumstances that may prevent us from retrieving your child from school, please call our office immediately
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Some appointments patients will NOT be able to ride on the BRACE BUS, as in banding, de-banding, reposition and laser procedure appointments. A parent or guardian will need to be present for these appointments
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Financial Accounts MUST stay current in order to participate in Brace Bus
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Patient’s Name
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First Name
Last Name
Parent/Guardian Print Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
School Name
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Grade
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HR Teacher
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Signature
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Clear
Should be Empty: