Authorization for Non-Parent/Guardian to Accompany Patient

Kid Safe, Kid Friendly

Authorization for Non-Parent/Guardian to Accompany Patient

Our office encourages that all parents/legal guardians accompany their child to each dental appointment. If the parent is unable to accompany the child to their dental appointment or recall visits please fill out this form. This authorization form grants permission to bring your child in, speak to the doctor and gives authorization for treatment. Treatments to be performed include routine pediatric dental services (examinations, cleanings, radiographs, fluoride treatment, and restorative needs as have been already fully explained to me). The initial patient registration, all medical/dental history must be filled out by parent or legal guardian.

I

give the person(s) listed below permission to bring my child to Leeward Pediatric Dentistry and to discuss and share dental information about my child. I further authorize them to see all necessary dental records and make health care decisions of a routine nature as determined at the sole discretion of Leeward Pediatric Dentistry, Dr. James M. Hori and Dr. Bryan I. Sato. I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent. This person shall also be responsible for any payments due at time of service.

Child's Name

Date of Birth

Child's Name

Date of Birth

Child's Name

Date of Birth

Name of authorized person

Relationship

Name of authorized person

Relationship

Signature (Parent/Guardian)

Date

James M. Hori, DDS • Bryan I. Sato, DDS
94-229 Waipahu Depot St. Ste. 501 Waipahu, HI 96797
Phone: (808) 671-0055 • Fax: (808) 671-3443
www.LeewardPediatricDentistry.com