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)



    Person Authorized 2



    Person Authorized 3



    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.

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