mainepedo.com - Guardian Consent Form

GUARDIAN CONSENT
I,   Parent/legal guardian   , give my consent to have   Person accompanying child
Bring my child   Child’s name   to his/her dental appointment
Authorize   Person accompanying child   to make all medical & dental treatment

Decisions on behalf of my child:    For today’s visit     For all future visits
Parent/Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

GUARDIAN CONSENT