Form

AUTHORIZATION FOR FRIEND OR FAMILY TO ACCOMPANY PATIENT

Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member, friend, or caregiver. We understand these circumstances may arise; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person bringing your child will need to present a photo identification at time of service. This authorization gives the person permission to bring your child(ren) in, speak to the doctor, give authorization for treatment, medication, certain procedures and make general health decisions.

Child #1: First & Last Name

Child #2: First & Last Name

Child #3: First & Last Name

Child #4: First & Last Name

Authorized Non Guardian # 1: Full Name

Authorized Non Guardian # 2: Full Name

I give the person(s) listed above permission to bring my child to Bird Pediatric Dentistry and to discuss and share medical information about my child.

I further authorize them to see any necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the Bird Pediatric Dentistry Provider.
I also give them authority to make more serious or urgent health care decisions in the event I
cannot be reached or where it is of an emergency nature where there is not sufficient time to seek
out my specific consent.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date