Child Consent Form

Freeman Dental - Mayfield

Please correct the errors described below.

Effective January 1st, 2018, Freeman Dental will be having every patient sign consent at treatment. Children under the age of 18 must have a parent or legal guardian to sign for consent. It is best that children are brought for dental treatment by a parent or legal guardian. We understand that some teenagers are able to drive themselves, however we still have to have a parent or legal guardian with the teenager to be able to sign consent. There may be times when someone other than you takes care of your child. That person may be a babysitter, teacher, or family member. If your child must be seen at Freeman Dental, PLLC during these times, we need the person who brings your child to be able to sign a consent form for Freeman Dental, PLLC to provide dental care. This form allows the person you choose to seek dental treatment and sign consent for your child when you are unable to come with the child. The person you name must be 18 years of age or older.

I understand that a parent or legal guardian must accompany my child to all dental visits. I understand that if a parent or legal guardian is unable to accompany the child, then I am aware that a designation of another person to consent for dental care form must be filled out prior to the scheduled dental visit.

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