Interest in Dental Cleaning Services at AHS Question Title * 1. Are you interested in your student receiving dental cleaning services at ACES Academy? Yes No Question Title * 2. Would you be willing to provide insurance information for the dental services? Yes No Question Title * 3. Would you be willing to sign a consent form for the dental services? Yes No Question Title * 4. Do you have any specific concerns or questions about the dental services provided by the mobile dentist and hygienist? Question Title * 5. How important is it for you to have dental services available on-site at ACES Academy? Very Important Important Neutral Not Very Important Not Important at All Question Title * 6. Please provide any additional comments or suggestions regarding the dental cleaning services at ACES Academy. Question Title * 7. Parent/Guardian Name Question Title * 8. Parent/Guardian Email Question Title * 9. Parent/Guardian Telephone Number Done