Notice to Revoke “Designation of Another Person to Consent for Dental Care”

Freeman Dental - Mayfield

Please correct the errors described below.

to consent for dental care of my child.

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.

For Office Use Only

In order to process your Notice to Revoke, please bring this form with you to your next visit or fax it to Freeman Dental, PLLC at (270) 247-5471 for the Mayfield Location. Thank you.

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