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:
Authorization for other individual to accompany minor patient under 18 years of age.
Authorization for minor patient to be unaccompanied for visits.
*Note: Consents are NOT required in emergency situations.*
Security Measure