www.ampsmiles.com- Consent to Treat a Minor by Non-Parent or Non-Guardian Form

Consent to Treat a Minor by Non-Parent or Non-Guardian
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
I {patientName}, the undersigned, am the parent or legal guardian of the above-named minor and hereby authorize the following individual(s) to consent to dental evaluation and treatment on my behalf:
Authorized Caregiver Information
Authorized Caregiver Name
Relationship to Patient
Caregiver Phone Number
Please enter a valid phone number.
Scope of Authorization
This authorization allows the caregiver named above to consent to the following dental services and procedures for my child at Amp Orthodontics & Kids Dental:
- Comprehensive and limited oral evaluations (exams)
- Diagnostic imaging (e.g., x-rays)
- Preventive services (e.g., cleanings, fluoride treatments, sealants)
- Orthodontic consultations and assessments
- Restorative treatments (e.g., dental fillings, crowns, space maintainers)
- Emergency dental treatment
- Administration of local anesthesia when appropriate
- Other treatments deemed necessary by the dental provider for the health and comfort of the child
I understand that this consent is valid unless I revoke it in writing. I also understand that I may be contacted prior to any significant or unexpected treatment.
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
I am the legal parentI am the court-appointed legal guardian (documentation may be required)
Please include a copy or photo of your government-issued ID to verify your identity and authorization.

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All personal and health-related information submitted through this form will be handled securely and in compliance with HIPAA regulations.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
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Consent to Treat a Minor by Non-Parent or Non-Guardian

Authorized Caregiver Information

Scope of Authorization

Parent/Guardian Information

Privacy Assurance