Bright Smiles from Birth Fluoride Varnish Consent Form

Posted on: April 14, 2010


Bright Smiles from Birth is an ICAAP educational program that provides guidelines and support to Pediatricians and Family Physicians, Dentists, and families to make oral health a component of well child visits.

Bright Smiles from Birth made available this consent form for application of fluoride varnish to a child’s teeth as part of the Fluoride Varnish Program.  Written consent is not required for application of varnish.  These forms are provided for providers who wish to obtain written consent.


Download this form in English and Spanish (pdf).


For more information about the Fluoride Varnish Program, or Bright Smiles from Birth please contact:

Jennie Pinkwater
Director, Prevention Projects
1400 W. Hubbard
Chicago, IL 60642
Phone: 312/733-1026, ext 213
Fax: 312/733-1791