Kids Dental Care

Authorization for Third Party To Consent To
Treatment of a Minor

I am the
Parent
Guardian
other person
having legal custody
(Must provide photo id)
(Describe legal relationship)
Of (name of minor) , a minor.

I hereby authorize ( ) X-Ray examination, anesthetic, dental diagnosis, or treatment of the licensed dentist.

I hereby authorize ( ) to sign all informed consents and any and/ or required treatment plans pertaining to the child's visit.

I understand that this authorization is giving in advance of any specific diagnosis, treatment being required, but is given to provide authority to the above-named agent to give consent to any and all such diagnosis, treatment which a licensed dentist recommends.

These authorizations shall remain effective until , unless sooner revoked in writing delivered to the agent named above.
Date: Time:
AM PM
Signature:
(Select relationship:
Parent Legal Representative Person Having Legal Custody
)

Print Name:
(Select relationship:
Parent Legal Representative Person Having Legal Custody
)

Witness:

Medically Relevant Information (Required)
Minor's Name:
Minor's date of birth:
Allergies to drugs or food:
Condition for which minor is currntly being treated:
Current Medications:
Restrictions on activity:
Primary care physicial (name and telephone number)
Please enter code above in the field below.