Pediatric Dentistry of Winchester: Consent for Non-Guardian

Pediatric Dentistry of Winchester: Consent for Non-Guardian

Donna Klein, DMD | 2560 Bypass Road #2, Winchester, KY 40391
In order to make your visit as prompt and as pleasant as possible, please provide the following information:
Patient's Full Name*

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As guardian, I hereby give the following person(s) my permission to bring my child/children to Pediatric Dentistry of Winchester.
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Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Guardian's Full Name

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Today's Date

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Guardian's Signature:*

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