Mt. Sterling Pediatric Dentistry - Non-Guardian Treatment Consent Form

Non-Guardian Treatment Consent Form

Please list the name of an individual that is not your child's guardian, mother, or father, but is given your permission to bring your child to their appointment.
I, (parent/guardian name) , give Mount Sterling Pediatric Dentistry permission to treat/see (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) .
The following individuals that are at least 18 years of age are also permitted to bring my child to the appointment.
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to Patient
Non-Guardian Name
Relationship to 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