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.