Mt. Sterling Pediatric Dentistry - Non-Guardian Consent Form Logo
  • Non-Guardian 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,       ,  give Mount Sterling Pediatric Dentistry permission to treat/see , while I am not present.

  • The individual bringing my child to the appointment is named,      and is at least 18 years of age. Their relationship to the patient is      .

  • 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.

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