MEK 2/22/22
Parent/Legal Guardian Consent for Dental Treatment
_________________________________________ ____________________
Child’s Name Date of Birth
_________________________________________ ____________________
Child’s Name Date of Birth
_________________________________________ ____________________
Child’s Name Date of Birth
_________________________________________ ____________________
Child’s Name Date of Birth
__________________________________ _____________________ _____________________
Parent/Legal Guardian Contact Phone Number #1 Phone Number #2
In the absence of a parent/legal guardian: The following named caregiver(s) is (are) hereby
authorized to consent for all dental treatment, for the above-named child(ren), which may be required during
my absence. I agree to pay for all services provided to my child(ren) that the caregiver authorized.
_______________________ ____________________ ________________ ______________
Authorized Caregiver’s Name Relationship to Patient Home Phone # Cell Phone #
_______________________ ____________________ ________________ ______________
Authorized Caregiver’s Name Relationship to Patient Home Phone # Cell Phone #
This consent serves as permission for treatment by KidZdent for the above-named child(ren).
This authorization will remain in effect until I revoke this authorization in writing and submit it to
KidZdent.
Signature of Agreement & Authorization
______________________________________ _________________
Parental/Legal Guardian (circle one) Date
______________________________________ _________________
Parental/Legal Guardian (circle one) Date
If circumstances permit and/or if KidZdent needs to contact me, please contact me at the following phone
number: ______________________
****NOTE: Consents are NOT required in emergency situations. ****
