3rd Party Authorization Form

Today's Date *

Month Day Year

Authorizing Adult/Guardian's Name *

First Name Last Name

Child's Name *

First Name Last Name

Child's Date of Birth *

Month Day Year

Name of Adult You Are Authorizing *

First Name Last Name

Contact Information of Adult You are Authorizing *

I do hereby give permission for the adult listed above (Adult You Are Authorizing) to bring my child, listed above, to dental appointments at My Friend’s Dentist to perform dental services in my absence.

I understand that during treatment it may be necessary to change or add procedures because of conditions found during the patient’s scheduled treatment and I give my permission to the dentist to make and all changes as they find necessary.

I also authorize the adult listed above (Adult You Are Authorizing) to make any and all necessary decisions, medical or otherwise, if a medical emergency arises.

Signature *