In an age of independence a parent/guardian may drop a patient off or the patient may drive themselves to their dental appointment. Although we prefer to always have a responsible adult accompanying a minor, we understand that some unforeseen circumstances might necessitate otherwise.

In order for us to be compliant with State laws and Dental Board regulations, we do require a signed consent form that permits our providers to treat an unaccompanied minor.

• A minor is defined as a person who is 17 years of age or under.
• We reserve the right to insist a parent/guardian be present at treatment.
• The parent/guardian signing this form has to be legally authorized to provide consent. The parent/guardian who is authorized to provide consent may not necessarily be the one who is paying for treatment.
• Please confirm with our office that all parental contact information is current.
• The parent/guardian has to be available by phone during the treatment time.
• Please make sure we are alerted to the fact that the parent/guardian will be leaving prior to the start of treatment.
• Please make sure that the parent/guardian return just prior to the estimated time of treatment completion for pick up.

Therefore, we can only perform the following:

• Examinations
• X-rays and intra-oral imaging
• Cleanings
• Application of Fluoride
• Placement of dental sealants
• Necessary treatment previously diagnosed or diagnosed during today’s visit

I have read and understood the items listed above and authorize the dental providers at Sierk Children’s Denitstry to perform all the procedures they deem necessary at the time of service, even during my absence. In addition, in case of a medical emergency, I authorize the doctors to take any life saving measure to resolve the issue.

I accept full financial responsibility for all fees associated with treatment of my child during my absence hereby authorize Dr Jonathan Sierk and/or his dental team to process payment(s) as the dental office deem necessary to settle/pay my account in full at the time of treatment as well as after my dental plan had paid. 

 Minor Child Name 

Cardholder First  Name                               Cardholder Last Name 

Card Account Number 

Exp Date

Address