Additional Adult Consent

• Name(s) of Patient *

  Please list the names of each child this consent is allowed.

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  The purpose of this form is to allow you, the parent, the option of naming other adults to bring your child to the office of Marcy L. Keown, D.M.D., P.A. for dental evaluation and treatment. You will be giving permission for these adults to discuss your child's personal medical history with the staff of Dr. Marcy Keown as needed and to make medical decisions for you regarding the dental care of your child
• 1. Name of Adult
• Relationship to Child

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• 2. Name of Adult
• Relationship to Child

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• 3. Name of Adult
• Relationship to Child

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• 4. Name of Adult
• Relationship to Child

• This form may be modified in writing at the request of either parent.

  To add or remove an adult from this list, please fill out a new form, sign your name and date.
• Signature of Guardian *

  Typing your name serves as your signature.

• Relationship to Patient *
• Date * MM / DD / YYYY