Additional Adult Consent

  • Permission form for adults other than the parents or legal guardians to bring the child to the office for dental care, and to give consent to treat. The purpose for this form is to allow you, the parent, the option of naming other adults to bring your child to the office of University Dental Group for dental evaluation and treatment. You will be giving permission for these adults to discuss your child’s personal medical history with the staff of University Dental Group as needed and to make medical decisions for you regarding the dental care of your child. If there are no adults listed, then your child will only be seen when brought by the parent or Legal Guardian.
  • DateName of AdultRelationship to Child 
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  • This form may be modified in writing at any time at the request of either parent;/p: