Designation of Another Person to Consent for Dental Care

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.

cannot accompany my child,

, to Freeman Dental, PLLC. Therefore, I give permission to

as follows (check one):

I give permission for this person (name below) to seek dental treatment (including any type of procedure or surgery) and provide consent for such treatment if attempts to contact me are unsuccessful.

Child's Name

I give permission for this person (name below) to seek dental treatment (including any type of procedure or surgery) and provide consent for such treatment without having to contact me.

Child's Name

Expiration of Permission (check one):

This form will remain in effect until revoked by filling out the Notice to revoke form.

This form is VALID ONLY during the following timeframe:

Effective date:

Expiration date:

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

Medical Information

List the following information about your child:

Name of Child:

Last Name

First Name

Birth Date:

Please List Known Allergies:

Allergy

Add Another Allergy

Please List Medication(s) child is taking:

Medication

Add Another Medication

Other information we may need to know:

Your information will be encrypted.