Authorization for evaluation and/or treatment of a minor child unaccompanied by parent or legal guardian.A parent or legal guardian must accompany a child younger than 18 years of age to consent for all dental treatment provided by Dentistry for Children & Adolescents. Please complete this form if your child will be coming for a visit without a parent or legal guardian.
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Child's Name: *
Date of Birth: *
MM
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List other children names and DOB
I understand this authorization will remain in effect until the practice is otherwise notified of the designated care-taker's change in status. I understand that it is my responsibility, as legal guardian, to inform this practice of any changes to this authorization.
Authorization for other individual to accompany minor patient under 18 years of age.
Name of person(s) being authorized:
Relationship to Patient
To give consent for dental treatment by Dentistry for Children & Adolescents on behalf of my child(ren) listed above, which may be required in my absence. I understand that I am still financially responsible for any services provided to my child(ren) that were approved by authorized person(s).
Parent of legal Guardian Signature
Date
MM
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DD
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YYYY
Phone number (in case of emergency)
Authorization for minor patient to be unaccompanied for visits.
I authorize and give consent for my child(ren), listed above, to go independently to appointments and consent to all dental treatment by Dentistry for Children & Adolescents without the presence of a parent or legal guardian. I understand that I am still financially responsible for any dental expenses incurred by my child(ren) during these appointments.
Parent of legal Guardian Signature
Date
MM
/
DD
/
YYYY
Phone number (in case of emergency)
*Note: Consents are NOT required in emergency situations.*
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