TREATMENT WITHOUT PARENT/GUARDIAN CONSENT FORM

    I,

    (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.

    Parental contact information for questions regarding treatment of the child:

    Parent’s Name:
    Contact Info:
    Mailing Address:
    Signed:
    Date:
    Relationship to Patient: