CONSENT/AUTHORIZATION FOR DENTAL TREATMENT

CONSENT/AUTHORIZATION FOR DENTAL TREATMENT
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
It is the policy of Young Breath and Wellness (Terence QL Young, D.D.S., Inc) that all minors be accompanied by a parent or legal guardian for their dental visits. We do understand that under certain circumstances, you would prefer another caregiver to accompany them.

All minors seeking dental treatment MUST be accompanied by a parent/legal guardian during the initial office visit. After the initial appointment, a minor may be seen for treatment only with written authorization from the parent/guardian under the conditions specified in this consent. If you need to send your child to their appointment with an adult other than yourself/legal guardian, please complete this section:

I, (parent/legal guardian)

*, cannot accompany my child,(child’s name) *, to their appointment(s) with Terence QL Young, D.D.S.

Therefore, I give permission to:
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
Consent Conditions (check all that applies below):*

the consent to sign any and all forms required to give permission to Terence QL Young, D.D.S. to treat the dental needs of myself or my childthe consent to perform: exam, x-rays, cleaning, fluoride treatment, and any other dental treatment deemed necessary by Terence QL Young, D.D.S.the consent to the dental practice to discuss finances (treatment charges, account balances, next visit charges)the consent to the dental practice to discuss myself or my child’s future dental treatment needs (i.e. treatment plans)the consent to sign my or my child’s treatment plan once it has been presented by the dental staff. I understand this does not obligate me to the treatment, only that the office has informed me or my representative of the dental needs of myself or my child
I understand I am responsible for all charges or fees incurred and co-payments must be made at the time of service as our financial policy states. We will gladly process payments over the phone if a credit card is used.
Parent / Guardian Signature:*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: