CONSENT FOR DENTAL TREATMENT OF MINORS IN ABSENCE OF PARENT/LEGAL GUARDIAN

PLEASE NOTE that if there are any medical changes, the parent or legal guardian MUST speak directly with the dental health care provider.

Patient's Name

Date of Birth

This consent serves as permission for treatment by Hanson Dental Practice for the above-named child. The individual bringing my child to the appointment is: ________________________________________.

I give my authorization for all recommended dental treatment during my absence that may be required. I take financial responsibility for all services provided to my child.

Prophylaxis

X-rays

Fluoride

Exams

Emergency Dental Treatment

This authorization shall remain effective:

Today Only

One (1) year from date signed below

Until ____________________ (Month, Day, Year)

This authorization will remain in effect until the date stated above unless I revoke this authorization in writing and submit it to Hanson Dental Practice prior to this date.

Parent/Legal Guardian Name: ______________________________________________

Signature: ______________________________________________________________

Phone Number: _____________________________ Date: ______________________

Your information will be encrypted.