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Transfer of Records/Release of Information

This form is required by our practice to verify that we have your permission to release your child's dental records.

After completion of this form, you can e-mail, mail or bring the form to the office where your child is usually seen.

*******Please allow 3 to 5 business days to process this request.*******

Parent/Legal Guardian Consent for Dental Treatment

A parent or legal guardian MUST accompany any child under the age of 18 to all appointments. If a parent or legal guardian cannot accompany the child, a Consent for Dental Treatment Form must be completed and sent along to the appointment.

The Consent for Dental Treatment Form gives a child's caregiver, who is not the parent/legal guardian, permission to consent to dental treatment for your child(ren). This form must be presented when anyone other than the parent or legal guardian will be accompanying your child(ren) to our practice.

*IMPORTANT: All information requested on our authorization form must be completed, or we may be unable to treat your child(ren).

*IMPORTANT: Remember to send along this completed form any time your child is being seen by our practice by someone other than the parent or legal guardian.

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Dentistry for Children & Adolescents

  • Edina Office - 7373 France Ave. S., Suite 402, Edina, MN 55435 Phone: 952-831-4400
  • Burnsville Office - 14050 Nicollet Ave., Suite 100, Burnsville, MN 55337 Phone: 952-435-4102
  • Eden Prairie Office - 6385 Old Shady Oak Road, Suite 150, Eden Prairie , MN 55344 Phone: 952-932-0920

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