Authorization to Consent to Dental Treatment

I hereby authorize
Name of adult whose care the minor(s) has/have been entrusted:
to consent to any X-ray, examination, anesthetic, dental diagnosis, or treatment of
Child/Children
deemed advisable by a dentist or hygienist and provided by the dentist or hygienist or under that dentis's or hygienists' supervision regardless of where that treatment is provided.

This authorization is made clear under the Family code §6910
Signature

Clear
Date

MonthDayYear
Date
Name
Please specify your relationship to minor:

Parent with legal custodyGuardian with legal custody
Should be Empty: