Consent for Accompaniment of a Minor

***With the consent of the doctor, this form allows you (the legal guardian) to grant permission for your child (children) to* *be accompanied at future dental appointments by someone other than you.***

Please refer to our Notice of Privacy Practice and Office Policy Acknowledgement

It is our office policy that the patient be accompanied by a parent/legal guardian for the patient’s initial visit and for any restorative treatment appointments thereafter, unless consent is given by the doctor. If consent by the doctor is given, permission can be granted by parent/legal guardian. For routine/preventative appointments (excluding the initial visit to our office), the parent/legal guardian can authorize individuals to act on their behalf by signing below. This consent allows the authorized individual to discuss any matters pertaining to the appointment at hand and scheduling of future appointments, but consent for treatment by the parent/legal guardian must still be given for any future restorative treatment. Accompaniment of an authorized individual does not waive the responsibility for any payment that is required for the services rendered at that appointment.

PARENT/GUARDIAN MUST ATTEND FIRST VISIT

Your Name *

Relationship to Patient *

Authorized Individuals

1st Individual *

Relationship to Patient *

2nd Individual

Relationship to Patient

3rd Individual

Relationship to Patient

Patient Information

Patient Name *

Date of Birth *

2nd Patient Name (optional)

Date of Birth

3rd Patient Name (optional)

Date of Birth

4th Patient Name (optional)

Date of Birth

5th Patient Name (optional)

Date of Birth

I Give Consent *

I give permission to the individuals listed to confirm treatment, medical history, and can schedule/change appointments, and AUTHORIZE treatment for the patients listed.

By typing/signing your name below, you give permission for these details.

Signature *

Thank you for your authorization. It has been sent and will be ready for you to sign upon arrival at your first visit.

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