Dental Consent (For a Minor)

Please correct the errors described below.

Do hereby consent and allow Wooster Family Dental to handle any type of dental care for my child including but not limited to the administration of local anesthesia determined by the Doctor, X-rays, fluoride and any other care recommended or deemed as necessary for the welfare of my child.

**If someone other than the parent or guardian is bringing the minor to appointment:

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

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