Authorization for evaluation and/or treatment of a minor child unaccompanied by parent or legal guardian.A parent or legal guardian must accompany a child younger than 18 years of age to consent for all dental treatment provided by Dentistry for Children & Adolescents. Please complete this form if your child will be coming for a visit without a parent or legal guardian.

Authorization for other individual to accompany minor patient under 18 years of age.

I understand this authorization will remain in effect until the practice is otherwise notified of the designated care-taker's change in status. I understand that it is my responsibility, as legal guardian, to inform this practice of any changes to this authorization.

I authorize and give consent for my child(ren), listed above, to go independently to appointments and consent to all dental treatment by Dentistry for Children & Adolescents without the presence of a parent or legal guardian. I understand that I am still financially responsible for any dental expenses incurred by my child(ren) during these appointments.