I give my consent to the above listed authorized persons to accompany my child to the office of Pediatric Dental Partners for dental appointments and to make any necessary decisions regarding dental treatment for my child (patient name listed above), including but not limited to:
- The consent for this authorized person to sign any and all forms required to give permission to Pediatric Dental Partners to treat the dental needs of my child.
- The consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges) with the listed authorized person(s).
- The consent to Pediatric Dental Partners to discuss my child's future dental treatment needs (i.e. treatment plans)
- The consent for the authorized person(s) to sign my child's treatment plan once it has been presented. I understand that this does not obligate me to the treatment, but only that the office has informed me or my authorized representative of the dental needs of my child.
- The consent for the authorized person(s) to schedule future dental visit for my child.
I understand that this consent will be valid for one year unless I rescinded in writing prior to the expiration of this consent agreement.