Consent for Dental Treatment and/or Care of a Minor Child

Drs. Erin & Randy Elliott

Please correct the errors described below.

We realize that parents or legal guardians may not always be able to personally accompany their child to our office. However, Kentucky law dictates that a patient under the age of 18 CANNOT be treated without a parent or guardian’s consent. To ensure that your child may receive prompt dental care, please complete the following form/information.

Do hereby give consent for the following person or persons to request and authorize dental treatment for my child.

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The above person(s) have my permission to received dental information and to make dental decisions on behalf of my child

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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