Bluegrass Pediatric Dentistry Guardianship Authority

Guardianship Authority Form

To be completed if the patient is a minor (under 18 years old)
Authorized Individuals to Accompany Minor

You may designate individuals (e.g., grandparents, babysitters) who are authorized to bring your child to appointments and make limited treatment-related decisions in your absence.

The following individuals are authorized to accompany my child to appointments:

I understand that in my absence, these individuals may be asked to sign consent for treatment. However, they are not authorized to make healthcare decisions beyond the scope of the visit unless separately documented.
Parent/Guardian Initials:
I affirm that I am the legal parent or guardian of the child named above and have the legal authority to make healthcare decisions on their behalf. I understand that documentation of guardianship may be required if it is not evident or upon request by the practice.
Parent/Guardian Initials:
Relationship to Patient

ParentLegal Guardian (Documentation Required)Other
Signature of Parent/Guardian:

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Date

MonthDayYear
Date
This guardianship authorization will remain in effect for 12 months from the date listed above.
Parent/Guardian Initials:
Should be Empty:

Guardianship Authority Form