Authorization for Non-Parent/Guardian Consent

Our office encourages that all parents or legal guardians accompany their child to each dental appointment. If the parent is unable to accompany the child for their initial dental appointment or recall visit, please fill out this form. This consent however, does not extend for dental treatment under oral conscious sedation or general anesthesia. If we are unable to obtain consent and /or information needed, we will need to reschedule your child’s appointment.

(*) indicates a required field.

Please select an office location *

Today's Date *

Child(ren) names(s) *

Authorized caregiver's name *

Relationship to child *

Caregiver's Phone Number

I give permission for the above named caregiver who I authorize to accompany the above named child(ren) for their initial examinations and subsequent recall visits. Treatment to be performed includes routine pediatric dental services (examination, cleanings, radiographs, fluoride treatment, and any treatment needs that have been explained to me.) The initial patient registration forms, all medical and dental histories must be filled out by the parent or legal guardian.

This consent shall be effective from the date of signature until revoked by the parent or legal guardian.

I can be reached at this phone number

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)