Designation of Another Person to Consent for Dental Care

Freeman Dental - Mayfield

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Effective January 1, 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. However, there may be times when someone other than you takes care of your child. That person may be a baby-sitter, 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. How to Use this Form:

1. Ask for or make several copies of this form.

2. Complete all the information on pages 2 and 3 of this form. Use a separate form for each child.

3. Sign and date the form and have an adult witness your signature. The person who will accompany your child can be the witness of your signature, but it can also be someone else.

4. Give the completed form to the person you have chosen. Have the person bring this form when he or she brings your child to Freeman Dental, PLLC. Please fill out a separate form for each person who may bring your child.

5. This form is kept in your child’s chart, but the person you have chosen should still bring a copy of the form with them.

6. By checking the appropriate box below, you can choose to have this form be valid until you revoke it or only during a designated time period.

7. If you have a need to revoke this form, please complete the information required on THIS FORM.

8. Be sure to tell the person who comes with your child to get the doctor's and assistant's instructions in writing before leaving Freeman Dental, PLLC. If you have questions about the instructions, be sure to call the office.

as follows (check one):

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