Permission to Accompany a Minor

Authorization for a designated adult to consent for and accompany a minor patient
I, (name of parent or guardian), the father/mother/legal guardian of (child patient) authorize (adult 18 years or older who will accompany child) to accompany my child (whom I am empowered to consent); and to give consent for any necessary dental procedures. This authorization will remain in effect until such time as I give notice of its termination.
Signature of Parent or Legal Guardian

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Authorization for a designated adult to consent for and accompany a minor patient