CONSENT FORM

World Pediatric Dental Consent to Communicate With Non Parent
 
It is Patient/Parent’s request that the practice communicate with a family representative on behalf of the parents/Guardians.
 

Name Patient 1 (required)

Name Patient 2

Name Patient 3

The following person(s) may attend visits and receive information regarding: Check all that apply
Treatment Scheduled to be PerformedFuture Treatment

Person Authorized 1(required)

Relationship(required)

Person Authorized 2

Relationship

Person Authorized 3

Relationship

Indicate when this authorization is valid for:

Only Valid for The Date Below One Time Authorization

Appointment Date

This authorization valid for any dates of serviceAll Future Services

Parent or Legal Guardian Name

Email Address

  
By Clicking this Box you agree to give consent to the above parties for the dates as described above. You are also agreeing that you are the person listed above and thus have authority to grant permission.