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

, am the parent of

Please immediately revoke prior permission for

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.

Signature of parent or legal guardian

Date and time signed

Signature of witness – 18 years of age or older

Date and time signed

Address

Home Phone

Work Phone

For Office Use Only

Office Use Only Revoked by

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.

Your information will be encrypted.