Authorization and Consent for Treatment Form
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk and that it is my responsibility to inform the dental office of any changes in my child's medical/dental status.
I understand that I will be informed of the recommended treatment for my child before any services are rendered and my signature authorizes procedures deemed necessary by the doctors and staff. I agree and understand (regardless of my insurance status), that the parent or guardian who accompanies the child is responsible for payment in full.