• Consent to Accompany a Minor Child

  • Patient NameDate of Birth 
  • I, (Parent or Legal Guardian), give permission to (Person/s to Accompany Patient) to accompany my child to Pediatric Dentistry for dental appointments.
  • the consent for this authorized person/s to sign any and all forms required to give permission to Pediatric Dentistry to treat the dental needs of my child on the day of service to discuss the needs and sign any forms pertaining to the future dental treatment needs (ie: treatment plans, consent forms, health history forms) of my child

    the consent for this authorized person/s to discuss treatment recommended, go over my child's dental needs and prevented care and post op instruction, details on procedures with the Doctors. Clinical Staff, or Administration Staff for my child

    the consent to the dental practice to discuss any account information and finances (details on account, treatment charges, accounts balances, next visits charges, Insurance Information) with this authorized person/s and for this person to schedule any future dental visits for my child

    I understand this consent will be valid for one year or until I rescind this agreement in writing.

  • This field is for validation purposes and should be left unchanged.