Form

Authorization for Third Party Consent to Treat of a Minor

I hereby authorize X-ray examination, anesthetic, dental diagnosis, or treatment of the licensed dentist.

I hereby authorize to sign all informed consents and any/or required treatment plans pertaining to the child's visit.

I understand that this authorization is giving in advance of any specific diagnosis, treatment being require, but is given to provide authority to the below named person to give consent to any and all such diagnosis, treatment which a licenced dentist recommends.

These authorizations shall remain effective for 12 months to the day unless sooner revoked in writing delivered to the agent named below.

Patient First Name

Patient Last Name

Date Of Birth

Third Party First Name

Third Party Last Name

Address

City

Zip Code

Third Party ID

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Parent/ Legal Guardian Full Name

Patient/Legal Guardian Signature

Date