Form

The purpose of this form is to allow you, the parent/legal guardian, the option of naming other adults to bring your child to the office of Michael Marfori, DMD for dental evaluation and treatment. You will be giving
permission for these adults (18 years of age or older) to discuss your child’s personal medical history with the staff of Dr. Marfori as needed and to make medical decisions for you regarding the dental care of your child.
If there are no adults listed, then your child will only be seen when brought by the parent or legal guardian.

AUTHORIZATION TO CONSENT TO DENTAL TREATMENT FOR A MINOR CHILD

I, parent/legal guardian of:

Patient's First Name

Patient's Last Name

Date Of Birth

Are there other siblings on this account to whom this authorization applies?

Please provide sibling's names and birthdates.

authorize the following individual(s) to obtain and consent to any and all dental care and treatment required for my minor child(ren) in my absence. As parent/legal guardian, my consent shall remain effective until this instrument is revoked by me in writing.

SIGNATURE OF PARENT OR LEGAL GUARDIAN

DATE SIGNED