Permission Form

Please type all information. Please include area code with all phone numbers.

I, the undersigned, give the individuals listed below permission to bring my child(ren) to their dental visits and authorize Tina P. Moses, DMD, PC to give them any information regarding dental care for my child(ren). They have full authority to make any dental and financial decisions for my child(ren), including but not limited to radiographs, fluoride treatments, nitrous oxide, and sedation. I understand that payment for services rendered is due at the time of treatment and agree to make payment arrangements if the individual accompanying my child(ren) is not prepared to make payment in full. Tina P. Moses, DMD, PC will make every effort to keep the accompanying adult informed before treatment is changed, however we realize that this may not always be possible and the adult will be informed of any changes at the completion of the appointment. I understand that if I need to make any changes to this agreement I must do so in writing.

Payment for services is due in full at the time of treatment unless prior arrangements have been made. If this account should go to collections, you will be responsible for all collection fees and any attorney fees.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.