Parental Consent Form

Parental Consent Form

Needed only for Patients Under 18 Years Old
Note: At Let’s Smile Dental, we value and appreciate our patients as well as their parents and guardians. To keep our workflow as efficient and as safe as possible, we have updated our policies with regards to who may bring a patient for an appointment:

•       If a child under the age of 18 presents by themselves without the parent or legal guardian, we will have to reschedule their appointment. Phone calls will not be accepted as confirmation of parental supervision.

•       If a parent or guardian is unable to be present at the time of the appointment, you may have an individual that is 18 years or older accompany your child if they are listed below, OR have filled out the parental consent form in-practice.

•       For new patient appointments, the legal parent or guardian must be present at the first appointment.
Do you plan on having someone other than a parent/legal guardian bring your child to their appointments?*
Please list all children below*
Authorized Caregiver's Name*

First NameLast Name
Relationship to Patient*
Authorized Caregiver's Phone Number*
Please enter a valid phone number.
Authorized Caregiver's Name

First NameLast Name
Relationship to Patient
Authorized Caregiver's Phone Number
Please enter a valid phone number.
By signing below, I give permission for the above name caregiver to be authorized to accompany the abovenamed child(ren) for their orthodontic appointments and subsequent recall visits. Treatment to be performed includes routine orthodontic services outlined during the initial consultation appointment. The initial patient registration package, all medical history/dental history must be filled out by parent or legal guardian. This consent shall be effective from date of signature until revoked by parent or legal guardian.
Parent / Guardian Full Name*

First NameLast Name
Parent / Guardian Full Name*

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