Consent to Accompany a Minor - Cochran & Soares Pediatric Dentistry

Consent to Accompany a Minor Child
Patient's*
Patient Name Date of Birth
Parent or Legal Guardian*
Email Address*
Person/s to Accompany Patient*
I, (Parent or Legal Guardian), give permission to (Person/s to Accompany Patient) to accompany my child to Pediatric Dentistry for dental appointments.
I also give permission to the person(s) named above to make any necessary decisions regarding dental treatment for my child, including but not limited to:*
the consent for this authorized person/s to sign any and all forms required to give permission to Pediatric Dentistry to treat the dental needs of my child on the day of service to discuss the needs and sign any forms pertaining to the future dental treatment needs (ie: treatment plans, consent forms, health history forms) of my child

the consent for this authorized person/s to discuss treatment recommended, go over my child's dental needs and prevented care and post op instruction, details on procedures with the Doctors. Clinical Staff, or Administration Staff for my child

the consent to the dental practice to discuss any account information and finances (details on account, treatment charges, accounts balances, next visits charges, Insurance Information) with this authorized person/s and for this person to schedule any future dental visits for my child

I understand this consent will be valid for one year or until I rescind this agreement in writing.
Phone
This field is for validation purposes and should be left unchanged.

Patient Name	Date of Birth

Consent to Accompany a Minor Child