POWER OF CONSENT

(Step parents also need authorization)

I, , the parent or legal guardian of, ,authorize the individuals below to accompany my child/children to visits and consent to necessary dental exams and/or treatment and disclosure of dental information regarding the initial and/or follow-up care of my child/children during the visits.

Name of person bringing child other than parent

Relationship to child

Name of person bringing child other than parent

Relationship to child

Name of person bringing child other than parent

Relationship to child

The person(s) named above may consent to the examinations and treatment for my child.

This authorization/consent is effective on

. This Document is effective until revoked by me in writing to Growing Smiles Pediatric Dentistry, PC.

Signature of Parent/Legal Guardian

Name of Parent/Legal Guardian