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.
I understand payment is expected at the time of treatment.