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 Performed Future 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 service All 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.

Translate »