Warr PDA Parent/Legal Guardian
Consent for Dental Treatment

All information in this form is confidential and transmitted over a secure, encrypted connection.
(*) indicates a required field.

Child's Name(s) *

Date of Birth *

Child's Name(s)

Date of Birth

Parent/Legal Guardian *

Phone Number *

Authorized Caregiver's Information

Caregiver's Name *

Home Phone Number *

Cell Phone Number

The above named caregiver shall be authorized to consent for all dental treatment for the above named child(ren), which may be required during my absence. The above named caregiver can also update the medical history of the above named child(ren). I agree to pay for all services provided to my child(ren) that the caregiver authorized.

If circumstances permit and/or Warr Pediatric Dental Associates needs to contact me, please contact me at the following telephone number:

This consent serves as permission for treatment and update of medical history by Warr Pediatric Dental Associates for the above named child(ren).

This authorization shall be effective until:

Parent/Guardian Initials (Please use your mouse or finger on a touchscreen to sign in the box.)
 

One (1) year from date signed OR until  

This authorization will remain in effect until the date stated above – unless I revoke this authorization in writing and submit it to Warr Pediatric Dental Associates prior to this date.

Parent/Legal Guardian *

Date *

Witness

Date