Form

AUTHORIZATION TO CONSENT TO DENTAL TREATMENT FOR A MINOR

Date Of Birth

, the legal guardian of the aforementioned, do hereby authorize the person(s) listed below to accompany my child(ren) to their dental appointments.

THE ABOVE MENTIONED CHAPERONE(S) ARE AUTHORIZED TO OBTAIN AND CONSENT TO ANY AND ALL DENTAL CARE AND TREATMENT REQUIRED BY SUCH MINOR CHILD IN THE ABSENCE OF THE UNDERSIGNED. MY CONSENT SHALL REMAIN EFFECTIVE UNTIL THIS INSTRUMENT IS REVOKED BY ME IN WRITING.

THE COMPLETION OF THIS FORM SUPERSEDES ALL PREVIOUS AUTHORIZATION TO CONSENT DENTAL TREATMENT FOR A MINOR CHILD FORMS (EXCEPT IN CIRCUMSTANCES OF JOINT CUSTODY FORMS).

SIGNATURE OF PARENT OR LEGAL GUARDIAN

DATE SIGNED

SIGNATURE OF PARENT OR LEGAL GUARDIAN

DATE SIGNED