Authorization for Agent to Consent to Dental Treatment of a Minor

Authorization for Agent to Consent to Dental Treatment of a Minor
I hereby authorize:
an adult into whose care the minor(s) has/have been entrusted*
to consent to any X-ray, examination, anesthetic, dental diagnosis, or treatment of:
Child/Children*
deemed advisable by a dentist or hygienist and provided by that dentist or hygienist or under that dentist’s or hygienist’s supervision regardless of where that treatment is provided.

This authorization is made under the Family Code §6910
Signed:*

Clear
Date:*

MonthDayYear
Date
Your Name*
Please specify your relationship to minor:*

Parent with legal custodyGuardian with legal custody
Should be Empty: