(Parent/Guardian name), give Gentle Touch Dentistry For All Ages, permission to treat my child,
(Child's name), while I am not present.
The individual bringing my child to the appointment is named, (Adult accompanying child) and is at least eighteen years of age and is the patient's (relationship to child).
I also give this individual permission to make decisions regarding my child’s dental treatment, medical treatment (if necessary should an emergency arise) and behavior management. I understand payment is expected at the time of treatment.
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