Parental Consent - Burnsville

Parental Consent - Burnsville

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.

Minor Patient(s):

Time Period:

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.

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

I Authorize:

To give consent for dental treatment by Dentistry for Children & Adolescents on behalf of my child(ren) listed above, which may be required in my absence. I understand that I am still financially responsible for any services provided to my child(ren) that were approved by authorized person(s).

Authorization for minor patient to be unaccompanied for visits.

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.

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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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