Pediatric Dentistry of Shelbyville - Treatment Consent Form

Non-Guardian Treatment Consent Form
I, (parent/guardian name) , give Pediatric Dentistry of Shelbyville permission to treat (child's name), while I am not present.
The individual bringing my child to the appointment is named, (adult accompanying child) and is at least 18 years of age. Their relationship to the patient is (Relationshop to the patient) .
I also give this individual permission to sign the treatment plan and make decisions regarding my child's
- Dental Treatment including fillings, extractions and stainless steel crowns.
- Medical treatment(if necessary should an emergency arise)
- Behavior management including the use of nitrous oxide and/or protective stabilization.
I understand payment is expected at the time of treatment.
Parent contact information for questions regarding treatment of the child:
Parent Name*
Contact Info: (Cell)
Contact Info: (Home)
Contact Info: (Work)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Signed (parent or guardian)

Clear
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

Non-Guardian Treatment Consent Form