Form

Permission Slip

Natalie A. Lenser D.D.S
Pediatric Dental Specialist
3109 Coffee Rd, Suite B
Modesto, CA 95355
(209)571-7283

Please be advised that this form simply allows someone other than a parent/legal guardian to bring a patient to an appointment in the future! A parent/legal guardian is required to be present at first visit. Your authorized person may approve services for prevention only and will be able to complete patient's health history on parent's behalf if needed. ONLY Parent/Legal Guardian can sign for treatment!

It is always a good idea to add anyone to the account even for "just in case" purposes for the future

Would you like to give permission for someone to bring your child(ren) to future appts?

Parent/Legal Guardian's Name

give

Authorized person over 18 yr (may list more than one person) First & Last Name

permission to bring my child(ren):

Patient's Name (may list more than one)

to see Dr. Natalie Lenser for all dental treatment necessary.

I authorize this between the dates of:

Start Date

End Date

may date out up to 5 years

Patient/Legal Guardian Signature

Date