Form

Consent for Treatment of a Minor

I am the parent or guardian of

who is a minor child, and I authorize the necessary examination and treatment by or under the supervision of Dr. Stacy Temple DMD and Dr. Shelagh Kavanagh DMD.

This includes, but is not limited to, exposure of radiographs as necessary, application of local anesthetic, and use of medication and materials for treatment.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date