Healthy Teeth, Healthy Child

AUTHORIZATION TO TREAT MINOR PATIENT IN ABSENCE OF PARENT/GUARDIAN & RELEASE OF ANY PATIENT INFORMATION.

I

, the parent or legal guardian of:

DOB

DOB

DOB

DOB

DOB

DOB

Hereby Authorize: The Release of any dental information pertaining to my child(ren)

(Name of person bringing child to office)

Relationship to patient

Phone number

(Name of person bringing child to office)

Relationship to patient

Phone number

To accompany my above named child(ren) to office visits with the Doctors and hygienists of Golnick Pediatric Dentistry and to consent to examination and/or treatment of my children during office visits. This authorization includes the administration of edications as well as the consent to deliver restorative, preventive and/or any other treatment deemed necessary. I also permit inancial issues regarding deductibles, copayments and insurance information to be communicated and updated. I am ultimately responsible for any and all services rendered. All of my questions regarding treatment options were discussed and answered. Additionally, the erson accompanying my child will be 18 years of age or older and may be asked to provide valid identmcation and will have a contact number available here I may be called if treatment changes or an emergency occurs. This agreement is valid until my child is 18 years old or graduated from our office.

I reserve the right to revoke this authorization at any time in writing to Golnick Pediatric Dental.

(Signature)

(Date)

Taylor: 313-292-7777

West Bloomfield: 248-668-0022