Consent for Minors

Consent for Treatment and Health Update for Minors

Patient Name

I am the (parent or guardian) of

who is a minor child and I authorize examination and treatment as necessary by or under the supervision of Dr Heidi Tzioros . This includes exposure of radiographs as necessary, use of local anesthetic, and use of appropriate medications and materials for such treatment.

Health Update

Has your child been in the hospital, had surgery or been under the care of a physician since the re last visit?

Yes No

If yes, please give a reason:

List all medication(s) your child is presently taking and the reason for the medication

List any medication(s) your child is allergic to:

Please list a phone number where you may be reached in the event that we need to speak with you during or after your child’s visit:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

If you have additional questions please call office before appointment date

Your information will be encrypted.

Consent for Minors

Consent for Treatment and Health Update for Minors

Health Update

***If you have additional questions please call office before appointment date***

Divine Dental

If you have additional questions please call office before appointment date